Every finding on record at Manor Court of Carbondale

Based on interview and record review the facility failed to ensure licensed nursing staff had active nursing licenses. This failure has the potential to affect all 102 residents residing in the facility.This past noncompliance occurred from 9/18/24 to 5/25/26.Findings include:V38's (Licensed Practical Nurse/ LPN) IDFPR's (Illinois Department of Financial and Professional Regulation) Lookup Detail View of V38's nursing license documented a First Effective Date of 08/15/2019 with an Effective Date of 02/27/2024 and an Expiration date of 02/28/2025. V38's IDFPR Lookup Detail also documented in part . Action. Refused To Renew. Discipline Start Date. 06/29/2026. Reason for Action. licensed practical nurse license has been placed in refuse to renew status after on June 18, 2024, Respondent was convicted of Obtaining a Controlled Substance by Fraud or Deceit, a level 6 Felony, under Case No.V39's (Registered Nurse/ RN) IDFPR's Lookup Detail View of V39's nursing license documented a First Effective Date of 05/01/2026 with an Expiration Date of 05/31/2028.On 7/29/26 at 2:04 PM, V2 (Director of Nursing/ DON) said V39's hire date was 9/18/24. V2 said V39 was originally hired into orientation until V39 brought in the documentation of a Pass score from taking the nursing boards. V2 said after he received V39's Pass V39 was allowed to work license pending under the direct supervision of a Registered Nurse. V2 said after 6 weeks of working license pending he assumed V39 had received her nursing license and was able to practice independently. V2 said he was unsure why he did not verify V39 had an active nursing license and it must have just been missed. V2 said V39 had applied to another facility and was notified she did not have an active nursing license and had called V2 to notify him. V2 said he called IDFPR to get clarification why V39 did not have an active nursing license and was told after V39 passed boards she failed to send in the final payment to get her license activated. V2 said V39 was removed from the schedule until an active nursing license was provided. V2 said after he was notified V39 did not have an active nursing license he completed an audit of all licensed nurses employed by the facility and found V38's nursing license had not been renewed and was not actively licensed. V2 said V38 was immediately removed from the schedule and was ultimately terminated due to V38's inability to get his license reactivated. V2 said all other licensed nurses employed by the facility were found to have active unencumbered nursing licenses. V2 said after the V38 and V39 were found to not have active licenses the facility would start completing an audit of nursing licenses upon hire, annually, and on years of nursing license renewal.The facility's Midnight Census Worksheet: as of 7/29/26 documented a total census of 102 residents residing in the facility.The deficient practice that began on 9/18/24 was removed prior to the survey date on 5/25/26 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review:On 4/30/2026, (V2) DON and (V1) Administrator were notified that there was one nurse, (V39) who did not have an active nursing license.(V39) was immediately removed from the schedule on 4/30/2026 to investigate the situation by the (V2) DON.V2 held a QAPI (Quality Assurance and Performance Improvement) meeting to develop the plan of correction with portions being reeducation of licensed nursing staff on license renewal, auditing all licensed nursing for active nursing licenses, and an ongoing weekly audit to be presented to the QA committee, and will review all nursing licenses upon hire, annually, and on renewal years. Upon investigation and running nursing licenses it was found 5/11/2026 that one more nurse, (V38) did not have an active nursing license. (V38) was immediately placed on leave on 5/11/2026 to investigate the situation by the (V2) DON.(V39) was able to obtain RN license on 5/1/2026 and was returned to work on 5/15/2026. (V39) licenses was confirmed active by (V2) DON on 5/11/2026. (V38) was unable to renew license at this time and was ultimately terminated on 5/15/2026 by the (V40) HR Manager. Plan of correction - All nurses employed by Manor Court of Carbondale had their licenses audited and printed to confirm active by(V40) HR Manager on 5/11/2026. All nurses have been educated that LPN's must renew their license on the odd years and RN's must renew their license on the even years. All nursing licenses will be ran upon hire and on renewal year (odd for LPN, even for RN) by the (V40) HR manager.The (V2) DON or designee will audit 3 nurses weekly for 4 weeks to ensure nurses have an active license. The results of these audits will be reported to the facility's Quality Assurance and Performance Improvement meeting.Date of Correction and Completion 5/25/2026

Based on interview and record review the facility failed to provide safe transfers using a transfer belt and implement appropriate interventions for injury for 2 of 6 (R7, R8) residents reviewed for accidents in a sample of 49. This failure resulted in R7 receiving multiple skin tears to his leg and pain in his shoulder. Findings include:1. R7's Face Sheet documents and admission date of 2/24/26 with included diagnoses of encephalopathy, unsteadiness on feet, cognitive communication deficit, fatigue, disorientation, pain in right knee, abnormalities of gait and mobility, pain, osteoporosis, osteoarthritis, spinal stenosis lumbar region, and weakness. R7's MDS (Minimum Date Set) dated 4/28/26 documents a BIMS (Brief Interview of Mental Status) of 5, indicating severe cognitive impairment. R7's Care Plan documents R7 is at increased risk for pressure ulcers and R7 currently has abrasions to the outside of his right knee, pressure injury to his left heel, left heel, right lateral foot, skin tear to left lower extremity and left leg near his knee (start date 2/24/25). Approaches of treatment to abrasions to the outside of right knee as ordered (start date 2/25/26) and access nails (start date 3/27/26). R7's physicians orders dated 5/14/26 document skin tear to left lateral lower leg, cleanse, pat dry, apply oil emulsion dressing and border gauze with a start date of 5/10/26 and open-ended end date. On 5/11/26 at 12:20 PM, V21 (R7's Emergency contact) stated R7 has gotten several skin tears while being transferred. V21 stated when staff transfer R7 they do not use a transfer belt most of the time, and they were hurting his shoulder that he had a torn rotator cuff in. V21 stated he was present yesterday (5/10/26) when R7 received a skin tear. V21 stated the CNA's were transferring R7 without a transfer belt and they were having a difficult time getting him to pivot and when they turned him, he hit his leg again in the same spot he does every time on the bed. On 5/13/26 at 11:01 AM, V21 stated R7 had gotten about 5 skin tears while he's been at this facility, and they all occurred while he was being transferred between his bed and the wheelchair. R7 stated the staff bump his leg on the same spot on the bed every time. R7 stated he feels like the staff have difficult time transferring R7 because he doesn't pivot very well and the staff have to turn him themselves. V21 stated the skin tears occur in the exact same 2 spots on his leg every time. V21 stated with one of the skin tears he told the CNAs that they just hurt his leg and when he looked, a piece of the bed had R7's skin hanging on it and blood dripping off of it. V21 stated he finally asked the facility, after the last skin tear on 5/10/26, to put foam over the spot on his bed that kept causing the skin tears. V21 stated he feels like the facility wasn't doing anything to prevent future injuries because they weren't addressing the problem. V21 stated every time he is at the facility, and he witnesses the CNA's transfer R7, they do not use a transfer belt, they just grab him under the armpits and that hurts him. V21 stated when R7 fell at home he landed on his shoulder, and it was getting better but it started hurting again from the staff lifting him from under his armpits. R7's Event Report dated 3/26/26 at 9:23 AM documents under Description; Skin tear to left lower extremity and under Event Details, Physical Assessment, Type of Injury; skin tear, under blood loss; small amount, under Activity During Skin Tear/Laceration Occurrence; Transferring and Other-on 2/24/26 in the afternoon. Under Notes it documents on 3/27/26 at 10:11 AM, Root Cause Analysis: Interdisciplinary Team met to discuss skin tear that was discovered on 03/26. Intervention of assess nails in place to prevent future occurrences. R7's Event Report dated 4/8/26 at 4:44 PM documents under Description; skin tear to left leg near knee and under Event Details, Physical Assessment, there are no details marked. Under Notes it documents on 4/8/26 at 5:50 PM, WEEKLY SKIN CHECK 1.) New ST (skin tear) to L (Left) leg below knee, tx (treatment) applied 5.0cm (centimeters)-2.5cm . R7's Event Report dated 5/10/26 at 12:44 PM documents under Description; Skin tear left lateral lower leg and under Event Details, Physical Assessment, Type of Injury; Skin Tear, under Blood Loss; small amount and controlled bleeding, and under Activity During Skin Tear/Laceration Occurrence; Transferring. Under Notes on 5/10/26 at 12:38 PM it documents Notified by CNA (Certified Nursing Aide) of skin tear to left later lower legs, just below the knee. Skin tear measures 2 x 1.5. Unable to approximate edges. Area cleansed with wound cleanser, patted dry. Oil emulsion applied and board [sic] gauze. Emergency contact (V27, Family Member), present in facility at the time of the event. R7's Progress note dated 3/09/26 at 5:01 PM documents This nurse went to assess residents R (right) knee. Upon assessment 2 abrasions noted. Areas have no drainage, odor, swelling or redness noted. No s/s (signs and/or symptoms) of infection will continue to monitor. R7's Progress note dated 3/24/26 at 2:20 PM documents previous skin tear to LLE (left lower extremity) was re opened-- one steri strip in place unable to approximate edges area cleansed with wound cleanser oil emulsion applied and covered with optifoam (V27) at bedside and is aware. R7's Progress note dated 3/27/26 at 10:11 AM documents [Recorded as Late entry on 3/30/26] Root Cause Analysis: Interdisciplinary Team met to discuss skin tear that was discovered on 03/26. Intervention of assess nails in place to prevent future occurrences. R7's Progress note dated 4/8/26 at 4:43 PM documents CNAs (Certified Nursing Aide) alert this nurse that residents L (left) leg was bleeding. Resident stated that he bumped his leg. Measuring at 5.0cm x 2.8cm. Steri strips applied, oil emulsion [sic], and DD (dry dressing). Resident compliant with tx (treatment). R7's Progress note dated 5/10/26 at 12:38PM documents Notified by CNA of skin tear to left lateral lower legs, just below the knee. Skin tear measures 2 x 1.5. Unable to approximate edges. Area cleansed with wound cleanser, patted dry. Oil emulsion applied and board gauze. Emergency contact (V21), present in facility at the of the event. On 5/13/26 at 2:34 PM, V11 (Occupational Therapist) stated he was seeing R7 for shoulder pain. V11 stated after R7 was admitted to the facility, R7 started having more shoulder pain and in his professional opinion he thinks it is because the CNA's don't use a transfer belt, they pick him up by under his arms. V11 stated R7 told him previously that the CNA's hurt his shoulders when they transferred him. V11 stated that anytime any resident is transferred, a transfer belt should be used because it is considered standard practice. V11 stated he has witnessed CNA's transfer residents without transfer belts before. On 5/13/26 at 2:21 PM, V18 (Physical Therapist) stated R7 was a 2-person transfer, and a transfer belt should be used but today R7 was changed to a stand-aid to help him transfer. R7 stated the CNA's said it was hard to transfer R7 so that is why he was changed to a stand-aid. V18 stated no resident that requires assistance should be transferred without using a transfer belt. On 5/13/26 at 3:29 PM, V19 (CNA) stated when R7 was a 2 person transfer she would put her arm under R7's arm in his arm pit/axilla area and lift him by his shoulder/arm. This surveyor asked V19 is she always used a transfer belt when transferring R7 and V19 replied she doesn't know. This surveyor asked V19 if she saw R7 transferred without a transfer belt before, and she answered maybe so this surveyor asked her again if she has transferred R7 without a transfer belt or if she has seen R7 transferred without a gait belt and V19 again answered maybe. On 5/13/26 at 3:28 PM, V20 (CNA) stated when R7 was a 2 person transfer she would put her arm under R7's arm in his arm pit/axilla area and lift him by his shoulder/arm. On 5/14/26 at 10:05 AM, V3 (Assistant Director of Nursing) stated R7 had a stat x-ray of his shoulder on 4/7/26 but she doesn't know why it was ordered because there isn't a note in the chart as to why. V3 stated the x-ray report documents it was completed due to shoulder pain. On 5/14/26 at 10:23 AM, V12 (License Practical Nurse) stated on 4/7/26 he received a verbal order from V10 (Nurse Practitioner) for an x-ray and a lidocaine patch to R7's shoulder and V10 stated it was because of shoulder pain but he doesn't know why R7 was having shoulder pain. On 5/19/26 at 11:20 AM, V10 stated she ordered an x-ray of R7's shoulder on 4/7/26 but she didn't make a note about it, but it was probably due to pain. On 5/14/26 at 2:24 PM, V1 (Administrator) stated the intradisciplinary team (IDT) talks about the event reports in their IDT meetings and there should be a root cause analysis for each event, and something put into place to prevent the accident from happening again for each event. 2. R8's face sheet documents an admission date of 05/13/25 with diagnoses including: cerebrovascular disease, type 1 diabetes mellitus with hyperglycemia, weakness, difficulty in walking, other abnormalities of gait and mobility, other symptoms and signs involving cognitive functions and awareness, muscle weakness, fatigue, unspecified convulsions, dizziness and giddiness, atrial fibrillation, cerebral infarction, enterocolitis due to clostridium difficile, diarrhea, urinary tract infection, and other muscle spasm. R8's MDS dated [DATE] documents a BIMS score of 12 indicating R8 is moderately impaired. R8's care plan documents a problem area of R8 is at risk for falling relating to diabetes, weakness, difficulty in walking, unsteadiness on feet, history of convulsions, history of stroke, atrial fibrillation, hypertension, and muscle spasms with interventions including: therapy to evaluate and treat as ordered, provide R8 with specialized equipment including wheelchair and walker, orientate resident to room/surrounding areas/ and use of call light system, instruct R8 to call for assist before getting out of bed or transferring and encourage resident to stand slowly, encourage R8 to use side rails/enablers as needed, and assist R8 with activities of interest dated 05/13/25, visual cues dated 09/30/2025, educate resident to ask for assistance with toileting dated 10/27/25, body pillows dated 01/05/26, and physical therapy to evaluate and treat dated 03/02/26. R8's event report dated 09/15/25 at 9:57 PM documents: on 09/15/25 at 9:57 PM R8 was found sitting on the floor beside his bed. R8 was in the wheeled recliner and slid on the floor. R8 stated he did not hit his head. This report documents no root cause analysis or intervention. R8's event report dated 09/28/25 at 5:51 AM documents a note dated 09/28/25 at 5:43 AM of this nurse was notified by CNA (Certified Nurse Assistant) R8 was found on the floor. R8 was laying on his side outside the bathroom door. This nurse ask R8 if he had tripped or gotten dizzy and R8 stated, I just fell and resident was helped back into bed. The note dated 09/29/25 at 3:24 PM documents: root cause analysis was discussed and intervention of visual cues in place to prevent future occurrence. R8's event report dated 10/25/25 documents an unwitnessed fall on 10/24/25 at 12:35 AM with a nursing note reporting: CNA (Certified Nurse Aide) alerted this nurse that R8 was on the floor. Upon entrance into R8's room R8 was noted to be sitting on the floor with his back up against the wall near his bed. When asked how he fell, R8 stated, I was trying to take myself to the bathroom and fell. There are no injuries noted at this time. R8's blood sugar was noted to be 88 and R8 was given juice. R8 stated, I hit my head on the wall but I'm okay neuro checks were put into place. This report notes on 10/27/25 at 8:57 AM documents: root cause analysis was discussed and intervention of educate resident to ask for assistance with toileting in place to prevent future occurrences. R8's event report dated 01/02/26 at 11:47 PM documents: a note dated 01/03/26 at 12:47 AM R8 was found sitting on the floor by the bed. R8 was able to explain what happened or what he was doing prior to being on the floor. This report documents a note dated 01/05/26 at 10:32 AM of root cause analysis was discussed for fall on 01/02 and intervention of body pillows in place to prevent future occurrences. R8's event report dated 03/01/26 at 12:57 PM documents a note dated 03/01/26 at 11:04 AM of CNA alerted this nurse R8 had an unwitnessed fall at bedside. R8 appeared to be attempting to get out of the recliner. R8 was sitting on his buttocks with legs crossed on the floor in an upright position. This not documents: R8 stated, I don't know when asked how he fell. Two CNAs assisted R8 back to his recliner. The note dated 03/02/26 at 8:49 AM documents root cause analysis was discussed and intervention of PT (physical therapy) to treat and evaluate to prevent future occurrences. On 05/11/26 at 10:52 AM there were no fall intervention signs present in R8's room. On 05/14/26 at 11:15 AM, R8 stated he does not remember if there ever were signs on his wall reminding him to use his call light or a stop sign on his wall. On 05/14/26 at 11:22 AM there were no stop signs or any fall prevention signs in R8's room. On 05/14/26 at 12:47 PM, V3 (Assistant Director of Nursing) stated, R8's fall on 09/15/25 should have a root cause investigation and an intervention put into place, it was missed. V3 stated, visual cues would include a stop sign or a sign stating call for assistance or something similar. V3 stated, R8's intervention of visual cues from the fall on 09/28/26 should be in place. On 5/18/26 at 8:39 AM, V1 stated they do not have specific policy for accidents.

Based on interview, observation, and record review the facility failed to provide assistance with meals for 5 (R9, R26, R60, R62 and R71) of 5 residents reviewed for eating assistance in a sample of 49.Findings include:1. R60's face sheet documents an admission date of 07/25/23 with diagnoses including: dementia, type 2 diabetes mellitus, weakness, hypertensive chronic kidney disease, vitamin B12 deficiency, anemia, hypothyroidism, spinal stenosis, and cerebral infarction.R60's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) score of 99 indicating severe cognitive impairment. R60's eating assistance is documented as setup or clean up assistance indicating helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. R60's progress note dated 03/30/2026 at 1:17 PM RD weight note. R60 has multiple diagnoses including dementia, diabetes mellitus type II, hypertension, hyperlipidemia, transient ischemic attack, cerebral infarction, and dysphagia. R60 requires assistance at meals in dining room.R60's progress note dated 05/08/2026 at 10:43 AM RD (Registered Dietitian) Quarterly note. R60 has multiple diagnoses including dementia, diabetes mellitus type II, hypertension, hyperlipidemia, transient ischemic attack, cerebral infarction, and dysphagia. R60 requires assistance at meals in dining room.R60's point of care history dated 03/01/26 - 05/14/26 documents: feeder-puree diet, nectar thick liquids, diabetic preferences.On 05/11/26 at 12:36 PM, R60 was sitting in the dining room and received assistance with his lunch.On 05/13/25 at 7:39 AM, R60's was sitting in the dining room with his breakfast sitting in front of him, R60 was making no movement to eat any of his food, at 7:52 AM staff started assisting R60 with his breakfast and R60 finished his breakfast with assistance.On 05/13/26 at 12:16 PM, R60 was in the dining room and received his lunch, at 12:21 PM staff offered R60 one bite of his food and left and delivered another lunch tray. At 12:27 PM staff assisted R60 with one more bite and walked off. At 12:41 PM staff offered R60 one more bite of his lunch and walked off. R60 took no bites of his food on his own without staff assistance. At 12:45 PM staff sat down to assist R60 with his lunch. 2. R71's face sheet documents an admission date of 01/09/23 with diagnoses including: vascular dementia, type 2 diabetes mellitus, gastro-esophageal reflux disease, hypothyroidism, deficiency of other specified B group vitamins, vitamin D deficiency, transient cerebral ischemic attack, cognitive communication deficit, anorexia, vitamin deficiency, type I diabetes mellitus, dysphagia, disorientation, dizziness and giddiness, disorder of thyroid, and diverticulitis of intestine.R71's MDS dated [DATE] documents a BIMS of 05 indicating R71 is severely cognitively impaired. R71's MDS documents R71's eating assistance as supervision or touching assistance indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R71's physician order sheet documents a dietary order of mechanical diet with thin liquids and a high calorie, high protein supplement dated 02/06/26 with an end date listed as open ended.On 05/11/26 at 12:36 PM, R71 was in the dining room and received her lunch. R71 made no movement to eat her lunch, at 1:03 PM R71 continued to stare forward and still had not eaten any of her lunch and unfolded a napkin and placed it over her food. R71 continued to sit in front of her food until 1:12 PM with no food eaten. During this time no staff had encouraged, cued or assisted R71 with her lunch.On 05/12/26 at 12:54PM, R71 was sitting in dining room in her wheelchair. R71's cake was sitting next to R71's plate covered with plastic wrap. R71's cake remained covered and was not eaten during the meal.R71's meal ticket dated 05/13/26 breakfast documents: regular diet with mechanical soft texture and high protein supplement. R71's meal ticket documents: food adds: fortified super cereal-8oz (ounces) and notes: double portion egg at breakfast, offer reduced sugar condiments, beverages, half portion of desserts, and 1 oz additional protein all meals.On 05/13/26 at 7:38 AM, R71 received her breakfast, at 8:02 AM R71 sat with her breakfast with her and still hadn't eaten any. During this time no staff had encouraged, cued or assisted R71 with her breakfast and it remained uneaten by R71.R71's meal ticket dated 05/13/26 dinner documents: regular diet with mechanical soft texture and high protein supplement. R71's meal ticket documents: offer reduced sugar condiments, beverages, half portion of desserts, and 1 oz additional protein all meals.On 05/13/26 at 12:26 PM, R71 received her lunch, R71 sat in front of her lunch making no movement towards eating it, at 12:53 PM R71 still had not eaten any of her lunch. During this time no staff had encouraged, cued or assisted R71 with her lunch and it remained uneaten.On 05/14/26 at 7:48 AM, R71 received her breakfast, R71 did not receive the double eggs with her breakfast. R71 received one fried egg, mixed fruit, hot cereal, a donut, and milk, juice, and coffee. R71 drank some of her juice then continued to sit there in front of her breakfast. At 8:16 AM R71 still had not eaten any of her lunch and during this time no staff had encouraged, cued or assisted R71 with her breakfast. At the end of the mean R71's food remained uneaten.3.R26's face sheet documents an admission date of 06/11/2020 with diagnoses including: unstable burst fracture of T11-T12 vertebra, Alzheimer's disease, type 2 diabetes mellitus, depressive episodes, personal history of traumatic brain injury, pain in right wrist, anorexia, cognitive communication deficit, vitamin deficiency, and obstructive sleep apnea.R26's MDS dated [DATE] documents a BIMS score of 03 indicating severe cognitive impairment. R26's eating assistance is listed as supervision or touching assistance - helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R26's care plan documents a problem area of nutritional status dated 03/21/25 documenting R26 has a history of weight loss. R26 is at risk for further impaired nutritional status relating to a history of pocketing food in her cheeks/mouth. R26 is on a mechanically altered/therapeutic diet. R26 requires staff assistance/supervision to complete her meals with interventions including: high calorie high protein supplement, staff assist with meal set up, and assist R26 at meal times and encourage food/fluid intake dated 10/16/25.R26's physician order sheet documents a dietary order of: mechanical soft solids, nectar thick liquids, and high calorie, high protein supplement dated 12/04/25 with an end date of open ended.On 05/11/26 at 12:31PM R26's meal ticket documented regular mechanical soft with mildly thickened liquids/nectar extra gravy on meat. At that time R26 was in the dining room and was eating her food with her hands. R26's silverware was rolled up in napkin food set in front of resident the silverware remained rolled in the napkin throughout lunch. At 1:00 PM R26 ate entire meal with her fingers. R26's thickened red drink continued to have plastic wrap over the top of the drink until 1:08 PM when staff removed the plastic wrap and moved the drink into R26's reach.On 05/12/26 at 12:47 PM, R26 was eating lunch in the dining room. R26 ate mechanically altered ham and potatoes, and poke cake with her fingers. R26's pudding still remained covered with plastic wrap. At 12:49 PM staff unwrapped the plastic off the pudding and R26 ate the pudding cup with her fingers and had pudding and poke cake all over her hand. During this time R26's silverware remained wrapped in a napkin in front of her and no staff assisted, cued, or encouraged R26 to use her silverware or assisted her with her silverware.On 05/13/26 at 7:35 AM, R26 was in the dining room and had received her breakfast. R26's drinks were still covered with plastic wrap and her silverware was still wrapped in a napkin. R26 ate her hot cereal with her fingers, after she finished her hot cereal R26 started eating her egg with her hands. R26 then started eating the english muffin and staff uncovered her drinks. R26 set the english muffin down and drank some of her thickened red drink, then picked her english muffin back up and finished eating it. During this time her silverware remained wrapped in a napkin and no staff assisted, cued, or encouraged R26 to use her silverware or assisted her with her silverware.On 05/13/26 at 12:16 PM, R26 was in the dining room received her lunch and her silverware was wrapped in a napkin next to the left side of her plate. At 12:25 PM R26 started eating her ground BBQ ribs with her fingers. At 12:27 PM staff uncovered her drinks. R26 continued eating her mashed potatoes, creamed corn, and pineapple upside down cake with her fingers. At 12:50 PM R26 finished her lunch and her silverware was still wrapped in her napkin and no staff assisted, cued, or encouraged R26 to use her silverware or assisted her with her silverware.On 05/14/26 at 7:43 AM, R26 was in the dining room and received her breakfast her silverware was wrapped in a napkin next to the left side of her plate and her drinks were still covered. R26 immediately took the donut off the plate and started eating it. At 7:47 AM staff took the plastic wrap off her drinks. R26 continued to eat her hot cereal and egg with her fingers. During this time, her silverware was still wrapped in her napkin and no staff assisted R26 to use her silverware.On 05/14/26 at 12:30 PM, R26 was in the dining room eating her ground ham and beans with her fingers, her silverware was still wrapped in her napkin and her nutritional shake still had the plastic wrap over the top. R26 continued eating her fried potatoes, carrots, and chocolate cream pie with her fingers. 4.R62's face sheet documents an admission date of 01/30/26 with diagnoses including: Parkinson's disease, dementia, protein calorie malnutrition, disorientation, vitamin deficiency, sciatica, cognitive communication deficit, major depressive disorder, and encephalopathy.R62's MDS dated [DATE] documents a BIMS score of 06 indicating severe cognitive impairment. R62's MDS documents his eating assistance as set up or clean up assistance indicating helper sets up or cleans up; resident completes activity, helper assists only prior to or following the activity. R62's care plan does not contain a problem area relating to nutrition or nutritional needs.R62's physician order sheet documents a dietary order dated 11/04/24 of: mechanical soft diet with HCHP (high calorie high protein) with an end date of open ended.On 05/11/26 at 12:36, R62 received his lunch in the dining room. R62 kept rolling his wheelchair backwards about three feet away from the table and then forward back up to the table. R62 continued to do this, at 1:04 PM R62 still had not eaten any food and no staff had encouraged R62 to eat.On 5/12/26 at 12:50 PM, R62's fortified milk had plastic wrap on the top of the glass of milk, at 12:52 PM, R62 was attempting to remove plastic wrap with a fork by slightly stabbing at it, at 12:55 PM, R62 successfully removed plastic wrap and started drinking fortified milk. On 05/13/26 at 12:20 R62 received his lunch in the dining room. R62 kept rolling his wheelchair backwards about three feet away from the table and then forward back up to the table. R62 continued to do this, by 12:53 PM R62 had eaten one bite of his food and no staff had encouraged R62 to eat. 5.R9's face sheet documents an admission date of 04/13/22 with diagnoses including: aphasia following cerebral infarction, latent tuberculosis, dementia, nutritional deficiency, cerebral infarction, dysphagia, anorexia nervosa, iron deficiency, diabetes mellitus, abnormal posture, and rheumatoid arthritis.R9's MDS dated [DATE] documents a BIMS score of 99 indicating severe cognitive impairment. R9's eating assistance is documented as supervision or touching assistance indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R9's physician order sheet documents a dietary order dated 09/17/24 of pureed solids with a high calorie high protein supplement with an end date listed as open ended.R9's care plan documents a problem are of resident care information dated 11/02/22 with interventions including: mechanical diet with pureed meats with thin liquids and a high calorie high protein supplement (no super cereal) with diabetic preferences. R9 is a 1x feeder at all meals dated 01/04/23. R9's care plan documents a problem area of nutritional status: R9 has a history of stroke with a diagnosis of aphasia, she has a diagnosis of dysphagia which puts her at risk for chewing, choking and swallowing difficulties dated 01/11/23 with interventions including: monitor for signs and symptoms of chewing, choking, or swallowing difficulties and report to speech language pathologist as needed and serve mechanical soft diet with pureed meats and thin liquids via straws. R9's care plan documents a problem area dated 05/19/22 of nutritional status: R9 has a history of weight loss, PO (per oral) intake is 25-75 % which puts her at risk for further weight loss with interventions including administer mirtazapine 7.5 mg (milligram) as ordered for appetite stimulant and monitor for side effects and obtain weights as ordered dated 01/11/23 and serve HCHP supplement per MD (medical doctor) orders. R9's care plan documents a problem area dated 05/13/22 of nutritional status: R9 has a diagnoses of dysphagia which puts her at risk for chewing, choking and swallowing difficulties with an intervention of serve pureed diet per MD orders dated 05/13/22.On 05/11/26 at 12:41 PM, R9 received her lunch in her room, at 1:04 PM R9 was in her room by herself with her lunch in front of her with R9 sleeping and no food eaten. During this time there were continuous observations made of anyone going into or coming out of R9's room from the hallway. No staff were seen going into R9's room providing encouragement or providing assistant after R9's tray was dropped off.On 05/13/26 at 7:43 AM, R9 received her breakfast in her room, at 8:04 AM R9 was in her room with her breakfast in front of her and no food had been eaten, at 8:30 AM R9's food was still in front of her and no food had been eaten. During this time there were continuous observations made of anyone going into or coming out of R9's room from the hallway. No staff were seen going into R9's room providing encouragement or providing assistant after R9's tray was dropped off.On 05/13/26 at 12:21 PM, R9 received her lunch in her room, at 12:55 PM R9 was slowly eating a few bites of her food in her room by herself, R9 had approximately 25% of her food eaten with about four drips of food on the towel covering her chest area.On 05/14/26 at 7:45 AM, R9 received her breakfast, at 7:49 AM R9 was in her room by herself with her food in front of her, surveyor stopped and asked how her food was and R9 looked down at her arm which was covered by a sheet, and asked if she could get some help. Surveyor was under the impression R9 wanted the blanket off of her hand and wrist so she could eat, so surveyor moved the blanket. R9's hand was very contracted and R9 was struggling with the spoon. R9 asked if she could get some help again, surveyor confirmed R9 wanted assistance eating and went and told a Certified Nurse Aide (CNA) R9 wanted some assistance.On 05/14/26 at 12:30 PM, R9 already had her lunch tray in her room. At 12:34 PM R9 was eating in her room by herself and struggling with her spoon. R9's spoon was at an approximate 80 degree angle and when R9 would get food onto the spoon, by the time she would get it to her mouth most of the food would fall off the spoon. At 12:42 PM R9 was still in her room by herself eating, R9 had gotten her spoon positioned better and was able to get a normal size bite. At 12:50 PM R9 had eaten approximately 0.33 percent of her food.On 05/14/26 at 3:05 PM, V1(Administrator) stated it is not the expectation that a resident would eat their food with their fingers, they should have been assisted with their silverware. V1 stated if due to their diagnosis such as dementia, they are not cognitively going to use the silverware and they still have the ability to feed themselves they should be recommended for a finger food diet. V1 stated, those items should all be care planned for the resident. V1 stated, part of set up for the resident's meals would include: unwrapping the silverware, removing any lids or plastic wrap, putting food and drinks within the reach of the resident and any other items that would make it easier for the resident to eat. V1 stated, if a resident was not eating she would expect staff within a few minutes to five minutes at most to encourage, cue, or assist that resident with eating. V1 stated, if a resident is being assisted to eat, she would expect the staff to sit down and assist the resident with their complete meal unless an urgent situation presented itself.The policy dated 02/04 titled, Feeding Assistance 3. Assist resident to a comfortable position 4. Tuck the napkin under the chin, 6. Feed resident slowly with fork or spoon, filled only half full 11. Record intake as required 12. Eating difficulties or lack of appetite should be reported to the physician.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person centered care plan for residents with dementia for 4 of 28 residents (R5, R10, R32, R43) reviewed for care plans in a sample of 49.Findings include:1. R10's face sheet documents an admission date of 2/8/26 with the following diagnoses in part; unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance and anxiety, unspecified psychosis not due to a substance or known physiological condition, altered mental status, cognitive communication deficit.R10's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 5, indication R10 is severely cognitively impaired.R10's current care plan does not document a focus area for dementia. 2. R43's face sheet documents an admission date of 12/28/25 with the following diagnoses in part; unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance and anxiety, metabolic encephalopathy, and unspecified psychosis not to a substance or known physiological condition.R43's Minimum Data Set, dated [DATE], documents a BIMS score of 5, indicating R43 is severely cognitively impaired.R43's current care plan does not document a focus area for dementia.On 5/14/26 at 2:40pm, V26 (Director of Memory Care) stated the main care plan coordinator, who is currently on leave, puts in most of the main focus areas in the care plans. V26 stated she then will add to it with things like activities and behaviors that she specifically deals with. V26 stated if she sees something that is missing, she will put it in. V26 stated that all residents with a diagnosis of dementia should have an individualized care plan, including a focus area for dementia, whether or not they are on the memory care unit. V26 stated she was not sure why V10 and V43 did not have a focus area for dementia.3. R5's face sheet documents an admission date of 10/07/2025 with the following diagnoses in part; unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbances, mood disturbances, and anxiety, Major depressive disorder, recurrent, moderate, Generalized anxiety disorder, and impulse disorder.R5's MDS dated [DATE], documents a BIMS score of 13 which indicates R5 is cognitively intact. Section I documents a diagnosis of non-Alzheimer's Dementia. R5's current care plan does not document an individualized focus area for dementia.On 05/13/26 at 1:30PM, R5 stated that she doesn't know if she has a diagnosis of dementia. R5 stated that she doesn't know any interventions that staff does for her other than assist her with care.On 05/14/26 at 10:22AM, V4 (Certified Nurse Assistant/CNA) stated that she doesn't think that R5 has a diagnosis of dementia. V4 said that she is not aware of any dementia care plan or interventions for R5 for dementia. V4 said she doesn't even think that R5 has any dementia, just behavior problems. On 05/14/26 at 10:26 AM, V13 (CNA) stated that she doesn't know about any dementia care plan or dementia care interventions for R5. V13 stated that she also doesn't know if R5 has dementia. 4. R32's face sheet documents an admission date of 05/29/20, with diagnoses in part; Unspecified dementia, unspecified severity, with other behavioral disturbance, vascular dementia, unspecified severity, with agitation, hallucinations, unspecified psychosis not due to a substance or known physiological condition, and Major depressive disorder, recurrent severe without psychotic features.R32's MDS dated [DATE], documents a BIMS score of 04 which indicates that R32 has severely impaired cognition. Section I documents a diagnosis of non-Alzheimer's Dementia.R32's current care plan does not document an individualized focus area for dementia.On 05/14/26 at 10:21AM, R32 stated that she doesn't know if she is on any special programs. R32 stated she couldn't tell me what staff does for her.On 05/14/26 at 10:22AM, V4 (Certified Nurse Assistant/CNA) stated that R32 does have episode of confusion. V4 said that R32 will forget how old she is or where she is at. V4 said that she wasn't sure if R32 had dementia or not. V4 said that R32's episodes of confusion are mild. V4 said that she doesn't think that R32 has a dementia care plan she stated that is usually the residents on the locked memory care unit. On 05/14/26 at 10:26AM, V13 (CNA) stated that R32 does have some problems with confusion. V13 stated that she doesn't know if R32 has a diagnosis of dementia or not. V13 stated that R32 does not have a dementia care plan that she knows of. V13 was not aware of any dementia care plans. On 05/14/26 at 2:14 PM, V14 (MDS/Care Plan Coordinator) stated that she does not do any dementia care plans. V14 said that she is only a stand in for the care plan nurse right now, because the care plan nurse is off on maternity leave. V14 said that she does parts of the care plan, but not any dementia care plans that would be V25 (Social Services Director). On 05/14/26 at 2:27PM, V25 stated that she doesn't do any dementia care plans. V25 said that she doesn't do any individualized care plan on dementia care. V25 said that staff on the memory care side probably do dementia care plans. V25 said that the facility does have dementia residents who are not on the memory care unit. V25 said that staff should know what to do with Dementia resident, because they get dementia care training when they are hired. On 05/14/26 at 3:00PM, V1 (Administrator) stated they do not have any specific policy on dementia care. V1 stated that the facility does have a locked memory care unit and that they don't have any specific policies regarding dementia care residents. V1 stated that staff are trained upon hire and annually on dementia and Alzheimer's care. V1 stated that she doesn't think the residents have a dementia care plan that they might have a care plan on activities and behaviors. V1 stated that all residents should have a care plan that is individualized for their care needs.

Based on interview, observation, and record review the facility failed to provide supplements as directed by the registered dietician and physician for 4 of 5 residents (R3, R26, R62, and R71) reviewed for supplements in a sample of 49.Findings include:1.R71's Face Sheet documents an admission date of 01/09/23 with diagnoses including: vascular dementia, type 2 diabetes mellitus, gastro-esophageal reflux disease, hypothyroidism, deficiency of other specified B group vitamins, vitamin D deficiency, transient cerebral ischemic attack, cognitive communication deficit, anorexia, vitamin deficiency, type I diabetes mellitus, dysphagia, disorientation, dizziness and giddiness, disorder of thyroid, and diverticulitis of intestine. R71's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 05 indicating R71 has severe cognitive impairment. R71's MDS documents R71's eating assistance as supervision or touching assistance indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R71's Order Sheet documents a dietary order of mechanical diet with thin liquids and a high calorie, high protein supplement dated 02/06/26 with an end date listed as open ended.R71's Dietary Note dated 01/02/2026 at 3:18 PM documents: RD (Registered Dietician) annual note: R71 is a [AGE] year old female with NKFA (no known food allergies). R71's height is 65 inches and on 12/18 (12/18/25) R71's weight was 154 pounds with a BMI (Body Mass Index) of 26%, weight review indicates no significant weight changes. R71's weights are fluctuating. R71's usual body weight is 155-156 pounds. R71 has a diagnosis of congestive heart failure with diuretic use with +1 non-pitting edema which can alter weights. R71 uses mirtazapine which may stimulate appetite. R71's estimated nutritional needs are 1750 kcals (kilocalories), 87 grams protein, and 1750 cc (cubic centimeters) fluid daily. Continue the M/S (mechanical soft), with DM (diabetic mellitus) preferences, HPS (high protein supplement) diet with double eggs at breakfast and monitor weights, skin, and blood sugar and refer prn (as needed) to the Registered Dietician. R71's meal ticket dated 05/13/26 breakfast documents: regular diet with mechanical soft texture and high protein supplement. R71's meal ticket documents: food adds: fortified super cereal-8oz (ounces) and notes: double portion egg at breakfast, offer reduced sugar condiments, beverages, half portion of desserts, and 1 oz additional protein all meals.R71's meal ticket dated 05/13/26 dinner documents: regular diet with mechanical soft texture and high protein supplement. R71's meal ticket documents: offer reduced sugar condiments, beverages, half portion of desserts, and 1 oz additional protein all meals. On 05/11/26 at 12:36 PM, R71 received her lunch. R71 did not receive 1oz extra protein with her lunch. R71 received a #6 scoop (2/3 cup) honey mustard chicken salad, caramelized naan bread, diced pickled beets, pear dump cake, and a red beverage.On 05/13/26 at 7:43 AM, R71 received her breakfast. R71 did not receive the double eggs with her breakfast. R71 received one egg patty in an English muffin with approximately 1/2 slice of cheese, mixed fruit, and hot cereal, and juice.On 05/13/26 at 12:26 PM, R71 received her lunch. R71 did not received the 1 oz additional protein with her lunch. R71 received a #8 scoop (1/2 cup) ground country style ribs with sauce, mashed potatoes and gravy, creamed corn, bread, pineapple upside down cake and a beverage.On 05/14/26 at 7:48 AM, R71 received her breakfast. R71 did not receive the double eggs with her breakfast. R71 received one fried egg, mixed fruit, hot cereal, a donut, and milk, juice, and coffee.On 05/14/26 at 12:30 PM, R71 received her lunch. R71 did not receive the one oz additional protein with her lunch. R71 received 8oz ground ham and beans, soft cooked fried potatoes, soft seasoned carrots, cornbread, chocolate cream pie, and a red drink.2. R26's Face Sheet documents an admission date of 06/11/2020 with diagnoses including: Alzheimer's disease, type 2 diabetes mellitus, personal history of traumatic brain injury, pain in right wrist, anorexia, cognitive communication deficit, vitamin deficiency, and obstructive sleep apnea. R26's MDS dated [DATE] documents a BIMS score of 03 indicating R26 has severe cognitive impairment. R26's eating assistance is listed as supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R26's Care Plan documents a problem area of nutritional status dated 03/21/25 documenting R26 has a history of weight loss. R26 is at risk for further impaired nutritional status relating to a history of pocketing food in her cheeks/mouth. R26 is on a mechanically altered/therapeutic diet. R26 requires staff assistance/supervision to complete her meals with interventions including: high calorie high protein supplement, staff assist with meal set up, and assist R26 at meal times and encourage food/fluid intake dated 10/16/25.R26's Order Sheet documents a dietary order of: mechanical soft solids, nectar thick liquids, and high calorie, high protein supplement dated 12/04/25 with an end date of open ended.R26's Progress Note dated 12/12/2025 at 1:28 PM documents : RD weight note. R26's pertinent diagnoses include: Alzheimer's/dementia, TBI (Traumatic Brain Injury) and, DM-II (type 2 diabetes mellitus). R26 eats in dining room and needs assistance at meals. Continue mechanical soft diet with nectar thick liquid, HCHPS (high calorie, high protein supplement), double eggs @ B (at breakfast), fortified pudding BID (twice a day). Include health shake daily. R26's Dietary Note dated 04/20/2026 at 8:34 AM documents: RD quarterly note. [AGE] year old female with NKFA. R26's pertinent diagnoses include: Alzheimer's/dementia, TBI and, DM-II. R26 eats in dining room and needs assistance at meals prn (as needed). R26's weight is 155 pounds with a BMI 28%. R26 uses mirtazapine as an appetite stimulant. Continue mechanical soft diet with nectar thick liquids, HCHPS, double eggs at breakfast, extra gravy with mechanical soft meats. Discontinue fortified pudding BID (contains high sugar content) and BS (blood sugars) have been elevated. R26's meal ticket dated 05/13/26 breakfast documents: regular diet with mechanical soft texture and high calorie high protein supplement. R26's meal ticket documents: notes: double portion egg at breakfast and extra gravy on mechanical meat.On 05/13/26 at 7:43 AM, R26 received her breakfast. R26 did not receive the double eggs with her breakfast. R26 received one egg patty in an English muffin with approximately 1/2 slice of cheese, mixed fruit, and hot cereal, and juice.On 05/13/26 at 12:26 PM, R26 received her lunch. R26 received a #8 scoop (1/2 cup) ground country style ribs with sauce, mashed potatoes and gravy, creamed corn, bread, pineapple upside down cake, pudding, a red beverage, and fortified milk.On 05/14/26 at 7:48 AM, R26 received her breakfast. R26 did not receive the double eggs with her breakfast. R26 received one fried egg, mixed fruit, hot cereal, a donut, fortified milk, and a red beverage.3. R62's Face Sheet documents an admission date of 01/30/26 with diagnoses including: Parkinson's disease, dementia, protein calorie malnutrition, disorientation, vitamin deficiency, cognitive communication deficit, and encephalopathy. R62's MDS dated [DATE] documents a BIMS score of 06 indicating severe cognitive impairment. R62's MDS documents his eating assistance as set up or clean up assistance indicating helper sets up or cleans up; resident completes activity, helper assists only prior to or following the activity. R62's Care Plan does not contain a problem area relating to nutrition or nutritional needs.R62's Order Sheet documents a dietary order dated 11/04/24 of: mechanical soft diet with HCHP (high calorie high protein) with an end date of open ended.R62's Dietary Note dated 03/25/25 at 12:14 PM documents: RD weight note: pertinent diagnoses include: Parkinson's, dementia, HTN (hypertension), history of UTI's (urinary tract infections). R62's weight on 03/21(3/21/25) is 174 pounds with a BMI of 30%. Continue mechanical soft diet with HCHPS and include fortified pudding twice a day at lunch and supper for additional calories/protein.R62's Dietary Note dated 02/20/2026 at 10:27 AM documents: RD quarterly note: R62 is an [AGE] year old male with NKFA. R62's pertinent diagnoses include: Parkinson's, dementia, HTN (hypertension), history of UTIs (urinary tract infections). R62's weight is 167 pounds with a BMI of 29%. Continue mechanical soft diet with HCHPS.R62's meal ticket dated 05/13/26 documents: regular diet with mechanical soft texture and HCHP listed as diet other. R62's meal ticket documents food adds as fortified super cereal 1 serving and beverages as 8 fluid ounces fortified whole milk. R62's meal ticket has a line through eggs [NAME] and under dislikes notes bread and rice.On 05/11/26 at 12:36 PM, R62 did not receive any fortified pudding with his lunch.On 05/13/26 at 7:45 AM, R62 received his breakfast. R62 did not receive any fortified super cereal or any egg. R62 received fruit, 4 oz hot cereal, an English muffin, and a red juice.On 05/13/26 at 7:45 AM, R62 stated he doesn't like bread, he didn't have an egg, and he didn't have any milk, he had juice.On 05/14/26 at 7:46 AM, R62 received his breakfast. R62 did not receive any fortified super cereal with his breakfast. R62 received, mixed fruit, 4 oz of hot cereal, one fried egg, one donut, and fortified milk.On 05/14/26 at 12:28 PM, R62 did not receive any fortified pudding with his lunch.4. R3's Face Sheet documents an admission date of 10/26/23 with diagnoses including: diabetes mellitus, ulcerative colitis, vitamin D deficiency, fibromyalgia, heart failure, cerebral infarction, muscle weakness, and gastro-esophageal reflux disease. R3's MDS dated [DATE] documents a BIMS score of 13 indicating cognitively intact. R3's eating ability is documented as setup or clean-up assistance.R3's Care Plan documents a problem area dated 06/06/25 of nutritional status stating R3 has experienced weight loss. R3 has ulcerative colitis, major depressive disorder, vitamin deficiencies, heart failure, and diabetes which can contribute to weight loss. R3 eats independently. R3 states she is okay with losing weight. R3's goal documents: R3 will maintain her weight during this quarter with interventions listed as: obtain weight as ordered and HCHP supplement dated 06/06/2025.R3's Order Sheet documents a dietary order dated 06/06/25 of regular diet with high calorie high protein supplement with an end date of open ended.R3's Progress Note dated 12/19/25 at 1:41 PM documents: RD quarterly note: R3's pertinent diagnoses include congestive heart failure, diabetes mellitus type II, ulcerative colitis, gastro-esophageal reflux disease, hypertension, a history of edema, and a new diagnosis of malignant melanoma - breast. On 12/05 (12/5/25) R3's weight was 218 pounds with a BMI of 35%. Continue regular diet with HCHP (supplement), and no SC (super cereal) at breakfast. Continue diabetic preferences at all meals with double eggs at breakfast and double protein portion at lunch and supper.On 05/11/26 at 12:41 PM, R3 received her lunch. R3 did not receive double protein with her lunch. R3 received a #6 scoop (2/3 cup) honey mustard chicken salad, caramelized naan bread, pickled beets, pear dump cake, and a red beverage.On 05/13/26 at 7:43 AM, R3 received her breakfast, R3 did not receive the double eggs with her breakfast. R3 received one egg patty in an English muffin with approximately 1/2 slice of cheese, mixed fruit, and hot cereal, and juice.On 05/13/26 at 12:26 PM, R3 received her lunch. R3 did not receive the double protein with her lunch. R3 received a #8 scoop (1/2 cup) ground country style ribs with sauce, mashed potatoes and gravy, creamed corn, bread, pineapple upside down cake and a beverage.On 05/14/26 at 7:48 AM, R3 received her breakfast. R3 did not receive the double eggs with her breakfast. R3 received one fried egg, mixed fruit, hot cereal, a donut, and milk, juice, and coffee.On 05/14/26 at 12:30 PM, R3 received her lunch. R3 did not receive the double protein with her lunch. R3 received 8oz ham and beans, soft cooked fried potatoes, soft seasoned carrots, cornbread, chocolate cream pie, and a red drink.On 05/14/26 at 3:05 PM, V1 (Administrator) stated the residents should receive all supplements directed by the registered dietitian or physician. V1 stated, if a resident does not like something on the menu such as eggs a different protein should replace that item.The diet spreadsheet dated day 9 lunch documents: regular diet: honey mustard chicken salad plate/lettuce #6 scoop/1 cup shredded lettuce, caramelized Naan bread 1 round, pickled beets 4 ounces, and peach dump cake 3 inches by 2.5 inch serving or #8 scoop, and a beverage.The diet spreadsheet dated day 9 lunch documents: mechanical soft diet: ground honey mustard chicken salad plate #6 scoop, soft caramelized Naan bread 1 round, diced pickled beets 4 ounces, and chopped peach dump cake 3 inches by 2.5 inch serving or #8 scoop, and a beverage.The diet spreadsheet dated day 10 lunch documents: regular diet: honey glazed ham #8 scoop with gravy, soft au gratin potatoes 4 ounces, seasoned green beans 4 ounces, soft bread/margarine 1 slice/1 teaspoon, soft chopped strawberry shortcake 4 ounces, and a beverage.The diet spreadsheet dated day 10 lunch documents: mechanical soft diet: ground honey glazed ham 3 ounces, au gratin potatoes 4 ounces, seasoned green beans 4 ounces, bread/margarine 1 slice/1 teaspoon, strawberry shortcake 4 ounces, and a beverage.The diet spreadsheet dated day 11 breakfast: documents: regular diet: assorted juice 6 ounce, fruit of the day 4 ounces, hot or cold cereal 4 ounce hot/ 6 ounce cold, eggs [NAME] 1 each, and milk/beverage.The diet spreadsheet dated day 11 breakfast: documents: mechanical soft diet: assorted juice 6 ounce, soft canned chilled fruit 4 ounces, hot or cold cereal 4 ounce hot/ 6 ounce cold, eggs [NAME] 1 each, and milk/beverage.The diet spreadsheet dated day 11 lunch: documents: regular diet: BBQ country style ribs 3 ounces, baked potato with sour cream 1 potato with 2 tablespoons, whole kernel corn 4 ounces, bread/margarine 1 slice/1 teaspoon, pineapple upside down cake 3 x 2 1/2 inches, and beverage.The diet spreadsheet dated day 11 lunch: documents: mechanical soft diet: ground BBQ country style ribs with sauce #8 scoop and sauce, mashed potatoes and gravy #8 scoop with 2 ounces gravy, creamed corn 4 ounces, soft bread/margarine 1 slice/1 teaspoon, pineapple upside down cake 3 x 2 1/2 inches, and beverage.The diet spreadsheet dated day 12 breakfast: regular diet: assorted juice 6 ounce, fruit of the day 4 ounces, hot or cold cereal 4 ounce hot/ 6 ounce cold, fried egg 1 egg, toast 1 slice, margarine/jelly 1 each, and milk/beverage.The diet spreadsheet dated day 12 breakfast: mechanical soft diet: assorted juice 6 ounce, fruit of the day 4 ounces, hot or cold cereal 4 ounce hot/ 6 ounce cold, fried egg 1 egg, buttered toast 1 slice with margarine/jelly 1 each, and milk/beverage.The diet spreadsheet dated day 12 lunch: regular diet: ham and beans 8 ounces, fried potatoes 4 ounces, seasoned carrots 4 ounces, cornbread/margarine 3 by 2 1/2 inches, cream pie 1/8th pie, and beverage.The diet spreadsheet dated day 12 lunch: mechanical soft diet: ground ham and beans 8 ounces, soft fried potatoes 4 ounces, soft seasoned carrots 4 ounces, soft cornbread/margarine 3 by 2 1/2 inches, cream pie 1/8th pie, and beverage.The facility policy dated 11/14/22 titled, Meal Service Procedure documents: to provide directions for meal services in order to deliver residents a palatable and attractive meal in a timely manner under proper food safety and sanitation guidelines. Staff should follow the meal tray ticket and serve the items the resident has requested.

Based on observation, interview, and record review, the facility failed to follow policy and procedures for infection control practices for 5 of 8 residents (R4, R5, R18, R46, and R54) reviewed for infection control in a sample of 49. Findings include:1. R4's Face Sheet documents an admission date of 2/20/26 with included diagnoses of gastrostomy status, malignant neoplasm of connective and soft tissue, and transient cerebral ischemic attack. R4's MDS (Minimum Data Set) dated 2/27/26 documents a BIMS (Brief Interview of Mental Status) score of 15, indicating R4's cognition is intact. Section K documents R4 had a feeding tube on admission and while a resident at the facility and R4 received 51% or greater calories and 501 milliliters per day or more of fluid intake through tube feeding. R4's Care Plan documents R4 has a gastrostomy tube and requires tube feedings (start date 2/20/26) with approaches of administer Jevity 1.5 Cal, 480 milliliters per gastric tube daily (start date 2/20/26). On 5/11/2026 at 2:54 PM, R4 stated he gets tube feedings three times a day. R4 stated they want him to get it more often, but he refuses. R4 stated he is getting tube feeding due to having a recent surgery to have a tumor removed in his neck and it messed his throat up. R4 stated when staff provide care to him, they do not wear a gown, they only wear gloves. On 5/13/26 at 11:27 AM, this surveyor observed V8 (License Practical Nurse/LPN) administer R4's tube feeding. An enhanced barrier sign was observed on the wall next to R4's door. V8 entered the room, performed hand hygiene then donned gloves. V8 performed R4's tube feeding per orders. V8 then removed gloves and performed hand hygiene. V8 was observed not wearing a gown during the entire observation. On 5/13/26 at 11:52 AM, this surveyor asked V8 if R4 was on any special precautions and V8 stated R4 is on enhanced barrier precautions. V8 stated she did not wear a gown while she was performing R4's tube feeding because she doesn't have to wear a gown when caring for him unless she is doing something with his urinary catheter. On 5/13/26 at 4:04 PM, V3 (Assistant Director of Nursing/ADON) stated that anytime a nurse is administering tube feeing to R4 or providing any kind of care they should wear a gown. 2. R46's Face Sheet documents an admission date of 4/1/23 with included diagnoses of multiple sclerosis, infection and inflammatory reaction due to indwelling urethral catheter, urinary tract infection, paraplegia, and urethral discharge. R46's MDS dated [DATE] documents a BIMS score of 15, indicating R46's cognition is intact. R46's Care Plan documents a problem area of R46 is at risk for infection related to indwelling catheter use (start date 5/13/24) with included approach of enhanced barrier precautions when giving care (start 5/13/24). On 5/11/26 at 10:00 AM, R46 stated she has a urinary catheter and she has some pain and rawness to her vagina. R46 stated that when staff provide any kind of care to her in her room, they only wear gloves and no gowns. On 5/11/26 at10:10 AM, while this surveyor was interviewing R46, V5 (Certified Nursing Assistant/CNA) came into the room to do a bed bath, urinary catheter care, and get R46 out of bed. V5 placed a clean towel over the bedside table and put a wash basin of warm water on the table along with a stack of clean wash cloths. V5 assisted R46 with cleaning her upper body then proceeded to perform urinary catheter care. V5 used a clean rag and wet it in the water then applied soap to the washcloth then wiped around the urinary catheter 4 times, using the same washcloth, folding it over each time. R46 then rolled over and V5 provided incontinence care, cleaning stool from R46's buttocks. R46 then rolled back over and V5 applied lubricant to R46's vagina around her urinary catheter. V5 was observed to wear the same gloves throughout this observation, not changing her gloves between incontinence care and applying lubricant. V5 then assisted R46 getting her clothes on. V6 (CNA) then came into R46's room, donned gloves then assisted V5 transferring R46 with a mechanical lift to her wheelchair. During this observation V5 and V6 were observed not wearing a gown. V5 and V6 stated they should have worn a gown when caring for R46. On 5/14/26 at 10:05 AM, V3 stated staff should wear a gown and gloves when caring for R46 due to her being on enhanced barrier precautions. 3. R18's Face Sheet documents an admission date of 5/5/26 with included diagnoses of dementia. R18's MDS dated [DATE] documents a BIMS score of 99, indicating the assessment was unable to be performed. R18's Care Plan documents R18 has an indwelling urinary catheter related to diagnoses of urine retention. On 5/11/2026 at 11:33 AM, observed R18 propelling herself in the hallway and her urinary catheter bag was hanging under her wheelchair with no privacy bag on it. R18's catheter bag and catheter tubing was dragging the ground. R18 was observed to roll over the catheter bag while propelling down the hallway. On 5/11/26 at 11:37 AM, V6 (CNA) got R18 and pushed R18 down the hallway with her urinary catheter bag and tubing dragging the floor and no privacy bag. V6 took R18 to the other end of the hallway. On 5/11/26 at 1:10 PM, V24 (CNA) was pushing R18 in the hallway to her room with no privacy cover on her catheter bag and the catheter tubing and bag were dragging the ground. On 5/13/26 at 4:04 PM, V3 stated for infection control purposes, urinary catheter bags and tubing should not drag the floor. On 5/18/26 at 8:39 AM, V1 (Administrator) stated they do not have specific policy for urinary catheter just the procedure for care. 4.R5's Face Sheet documents an admission date of 10/07/25 with diagnoses in part of acute cystitis without hematuria, retention of urine, infection and inflammatory reaction due to indwelling urethral catheter, and obstructive and reflux uropathy. R5's Minimum Data Set, dated [DATE] documents in Section C a BIMS score of 13, which indicates R5 is cognitively intact. Section GG documents toileting as substantial/maximal assistance. Section H. documents indwelling catheter. R5's Care Plan documents a Problem of R5 has history of UTI (Urinary Tract Infection) with a review date of 05/14/26 with interventions of 1. provide foley (Indwelling) catheter care twice a day and as needed. 2. encourage fluids. 3. monitor for symptoms of UTI R5's Care Plan documents a problem of R5 has an indwelling catheter r/t (related to) obstructive and reflux uropathy (start date 10/7/25) with interventions in part of do not allow tubing or any part of the drainage system to touch the floor and store collection bag inside of protective dignity pouch (start date 10/7/25). On 05/13/26 at 12:29PM, R5 was observed with indwelling catheter bag and tubing dragging on the floor in the dining room with no cover over collection bag. On 05/13/26 at 1:15PM, staff observed pushing R5 into the activity room. Observed R5's catheter bag and tubing dragging on the floor. R5's catheter collection bag was attached under R4's wheelchair to the center cross piece under the wheelchair. There was no bag cover observed over the collection bag. On 05/13/26 at 1:20PM, R5 stated that they do catheter care on her. R5 stated that she doesn't ever have a bag over her urine collection bag. R5 stated that they always place the urine collection bag and tubing under her wheelchair. 5. R54's Face Sheet documents an admission date of 01/28/26 with diagnoses of urinary tract infection, and obstructive and reflux uropathy. R54's MDS dated [DATE] documents in Section C. a BIMS score of 03 indicating that R54 has severely impaired cognition. Section GG documents toileting as dependent. R54's Care Plan documents a problem area of R54 has a history of UTI (Urinary Tract Infection) (start date 3/10/26) and a problem area of R54 has a chronic indwelling catheter related to obstructive uropathy (start date of 1/28/26). On 05/13/26 at 3:24PM, R54 was observed sitting in the dining area with her indwelling catheter collection bag and tubing dragging the floor as R54 was trying to wheel herself around in the dining area. There was no bag cover observed over collection bag of catheter. A facility policy titled Enhanced Barrier Precautions revised 3/28/24 documents under Key Points: 3. Enhanced Barrier Precautions are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices even if they resident is not known to be infection or colonized with multi drug resistant organisms, ii. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

Based on interview, observations, and record review the facility failed to promote dignity for 6 of 6 residents (R5, R18, R26, R54, R74, R83) reviewed for resident rights in a sample of 49. Findings include:1. R83's Face Sheet documents an admission date of 4/22/26 with included diagnoses of hypertension and symptoms and signs involving nervous system-stroke like. R83's MDS (Minimum Data Set) dated 4/29/26 documents a BIMS (Brief Interview of Mental Status) of 15, indicating intact cognition. On 05/11/2026 at 9:38 AM, R83 stated she has issues sleeping due to her roommate keeping her TV on loud all night and her roommate is up a lot at night. R83's roommate's television was observed to be loud during this interview with R83, making it difficult for R83 to hear this surveyor. On 5/13/26 at 3:04 PM, V5 (Certified Nursing Aide/CNA) stated R83's roommate does keep her TV loud and she tries to go turn it down when she hears it, but it gets turned back up after she leaves the room. V5 stated she has heard R83 complain about not getting sleep due to her roommate being too loud. On 5/13/26 at 3:07 PM, V17 (License Practical Nurse) stated R83 has complained to her before about not getting sleep at night because her roommate keeps her up at night. V17 stated the roommate makes R83 feel anxious and it's almost like R83 feels responsible for taking care of her and helping her because she is confused most of the time. V17 stated she told V25 (Social Services Director) about R83's roommate keeping her up at night. On 5/14/26 at 2:06 PM, V25 stated no one has told her anything about R83 not being able to sleep due to her roommate being too loud. On 5/14/26 at 2:24 PM, V1 (Administrator) stated she is not aware of R83 having difficulty sleeping due to her roommate being too loud. V1 stated if a resident tells a staff member that they are unable to sleep at night due to their roommate being too loud she would expect them to tell her or someone in administration so they can possibly do a room change. A facility policy titled Resident Rights dated 11/28/2017 documents under F550-Resident Rights; The resident has a right to a dignified existence, self-determination. and A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the right of the resident. 2. R26's face sheet documents an admission date of 06/11/2020 with diagnoses including: unstable burst fracture of T11-T12 vertebra, Alzheimer's disease, type 2 diabetes mellitus, depressive episodes, personal history of traumatic brain injury, pain in right wrist, anorexia, cognitive communication deficit, vitamin deficiency, and obstructive sleep apnea. R26's MDS dated [DATE] documents a BIMS score of 03 indicating severe cognitive impairment. R26's eating assistance is listed as supervision or touching assistance - helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R26's care plan documents a problem area of nutritional status dated 03/21/25 documenting R26 has a history of weight loss. R26 is at risk for further impaired nutritional status relating to a history of pocketing food in her cheeks/mouth. R26 is on a mechanically altered/therapeutic diet. R26 requires staff assistance/supervision to complete her meals with interventions including high calorie high protein supplement, staff assist with meal set up and assist R26 at mealtimes and encourage food/fluid intake dated 10/16/25. R26's physician order sheet documents a dietary order of mechanical soft solids, nectar thick liquids, and high calorie, high protein supplement dated 12/04/25 with an end date of open ended. On 05/11/26 at 12:31PM, R26's and in the dining room for lunch her meal ticket documented regular mechanical soft with mildly thickened liquids/nectar extra gravy on meat. At that time R26 was eating her food with her hands. R26's silverware was rolled up in napkin food set in front of resident. The silverware remained rolled in the napkin throughout lunch. At 1:00 PM R26 had eaten the entire meal with her fingers. R26's thickened red drink continued to have plastic wrap over the top of the drink until 1:08 PM when staff removed the plastic wrap and moved the drink into R26's reach. On 05/12/26 at 12:47 PM, R26 was in the dining room for lunch. She ate mechanically altered ham and potatoes, and poke cake with her fingers. R26's pudding still remained covered with plastic wrap. At 12:49 PM staff unwrapped the plastic off the pudding and R26 ate the pudding cup with her fingers and had pudding and poke cake all over her hand. During this time R26's silverware remained wrapped in a napkin in front of her and no staff assisted, cued, or encouraged R26 to use her silverware or assisted her with her silverware. On 05/13/26 at 7:35 AM, R26 was in the dining room for and received her breakfast. R26's drinks were still covered with plastic wrap, and her silverware was still wrapped in a napkin. R26 ate her hot cereal with her fingers. After she finished her hot cereal R26 started eating her egg with her fingers. R26 then started eating the english muffin and staff uncovered her drinks. R26 set the english muffin down and drank some of her thickened red drink, then picked her english muffin back up and finished eating it. During this time her silverware remained wrapped in a napkin and no staff assisted, cued, or encouraged R26 to use her silverware or assisted her with her silverware. On 05/13/26 at 12:16 PM, R26 was in the dining room and received her lunch, her silverware was wrapped in a napkin next to the left side of her plate. At 12:25 PM, R26 started eating her ground BBQ ribs with her fingers. At 12:27 PM staff uncovered her drinks. R26 continued eating her mashed potatoes, creamed corn, and pineapple upside down cake with her fingers. At 12:50 PM, R26 finished her lunch, and her silverware was still wrapped in her napkin and no staff assisted, cued, or encouraged R26 to use her silverware or assisted her with her silverware. On 05/14/26 at 7:43 AM, R26 was in the dining room and received her breakfast, her silverware was wrapped in a napkin next to the left side of her plate and her drinks were still covered. R26 immediately took the donut off the plate and started eating it. At 7:47 AM staff took the plastic wrap off her drinks. R26 continued to eat her hot cereal and egg with her fingers. During this time, her silverware was still wrapped in her napkin and no staff assisted R26 to use her silverware. On 05/14/26 at 12:30 PM, R26 was in the dining room eating her ground ham and beans with her fingers, her silverware was still wrapped in her napkin, and her nutritional shake still had the plastic wrap over the top. R26 continued eating her fried potatoes, carrots, and chocolate cream pie with her fingers. On 05/14/26 at 3:05 PM, V1(Administrator) stated it is not the expectation that a resident would eat their food with their fingers, they should have been assisted with their silverware. If due to their diagnosis such as dementia, they are not cognitively going to use the silverware, and they still have the ability to feed themselves they should be recommended for a finger food diet. 3. R18's Face Sheet documents an admission date of 5/5/26 with included diagnoses of dementia. R18's MDS dated [DATE] documents a BIMS of 99, indicating the assessment was unable to be performed. R18's Care Plan documents R18 has an indwelling urinary catheter related to diagnoses of urine retention. On 5/11/26 at 11:33 AM, observed R18 propelling herself in the hallway and her urinary catheter bag was hanging under her wheelchair with no privacy bag on it. On 5/11/26 at 11:37 AM, V6 (Certified Nursing Aide/CNA) was pushing R18 down the hallway with no privacy bag. On 5/11/26 at 12:42 PM, R18 was in the dining room eating lunch and her urinary catheter bag was hanging under her wheelchair with no privacy bag on it. On 5/11/26 at 1:10 PM, V24 (CNA) was pushing R18 in the hallway to her room with no privacy cover on her catheter bag and tubing and bag dragging the ground. On 5/13/26 at 4:04 PM, V3 (Assistant Director of Nursing) stated all urinary catheter bags should have a privacy cover on them when they are out of their room in the facility. On 5/18/26 at 8:39 AM, V1 (Administrator) stated they do not have specific policy for urinary catheter just the procedure for care. 4. R5's Face Sheet documents an admission date of 10/07/25 with diagnoses in part of acute cystitis without hematuria, retention of urine, infection and inflammatory reaction due to indwelling urethral catheter, and obstructive and reflux uropathy. R5's Minimum Data Set, dated [DATE] documents in a BIMS score of 13 which indicates R13 is cognitively intact. Section GG documents toileting as substantial/maximal assistance. Section H. documents indwelling catheter. R5's Care plan documents a problem of R5 has history of UTI (Urinary Tract Infection) with a review date of 05/14/26 with interventions of 1. provide foley (Indwelling) catheter care twice a day and as needed. 2. encourage fluids. 3. monitor for symptoms of UTI. R5's Care plan documents a problem of R5 has an indwelling catheter r/t (related to) obstructive and reflux uropathy with interventions in part of do not allow tubing or any part of the drainage system to touch the floor and store collection bag inside of protective dignity pouch. On 05/13/26 at 12:29PM observed R5's indwelling catheter bag and tubing dragging on the floor in the dining room no bag cover over collection bag. On 05/13/26 at 1:15PM staff observed pushing R5 into the activity room. R5's catheter bag and tubing were dragging on the floor. R5's catheter bag was attached under wheelchair to the center cross piece under wheelchair no bag cover over collection bag. On 05/13/26 at 1:20PM, R5 stated that they do catheter care on her. R5 stated that she doesn't ever have a bag over her collection bag. R5 stated that they always place the collection bag and tubing under her wheelchair. On 05/13/26 at 3:42PM, V3 (Assistant Director of Nursing) stated that all catheter bags should be covered. V3 stated that all catheter collection bags, and tubing should be off the floor and should not touch the floor at all. 5. R54's Face Sheet documents an admission date of 01/28/26 with diagnoses of urinary tract infection, and obstructive and reflux uropathy. R54's MDS dated [DATE] documents a BIMS score of 03 indicating that R54 has severely impaired cognition. Section GG documents toileting as dependent. R54's Care Plan documents a problem area of R54 has a history of UTI (Urinary Tract Infection). R54's Care Plan documents a problem area of R54 has a chronic indwelling catheter related to obstructive uropathy. On 05/13/26 at 3:24PM observed R54 sitting in the dining area in her indwelling catheter collection bag and tubing dragging the floor as R54 was trying to wheel herself around in the dining area. There was no bag observed over collection bag of catheter. 6. R74's face sheet documents an admission date of 3/13/26 with the following diagnoses in part; unspecified dementia, unspecified severity, with other behavioral disturbance, generalized anxiety disorder, other disorders of calcium metabolism, and muscle weakness. R74's Minimum Data Set, dated [DATE] documents a BIMS score of 9, indicating that R74 is severely cognitively impaired. Section GG-Functional Abilities documents that R74 is set up or clean-up assistance for eating. On 05/11/2026 at 11:54am, R74's entire table was served lunch except for her. The kitchen ran out of food, more food was brought in, and they began serving other tables. R74 was still not served her food. On 5/11/26 at 12:05pm, R74 stated she doesn't understand why everyone else got their food but her. R74 stated she guessed they'll get to her eventually. R74 stated it was upsetting for her that everyone had been served but her. On 5/11/26 at 12:11pm, R74 received her lunch. On 5/14/26 at 2:40pm, V26 stated all residents at the same table should be served at the same time. Facility Policy titled, Meal Service Procedure with an adopted date of 11/14/22, documents the following under the section Meal Service. Meals should be served to all residents at a table at the same time.

Based on observation, interview, and record review the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice that includes care of a non-pressure related skin condition for 1 of 2 (R46) residents reviewed for quality of care in a sample of 49. Findings include:R46's Face Sheet documents an admission date of 4/1/23 with included diagnoses of multiple sclerosis, infection and inflammatory reaction due to indwelling urethral catheter, urinary tract infection, paraplegia, and urethral discharge. R46's MDS (Minimum Data Set) dated 3/4/26 documents a BIMS of 15, indicating intact cognition. R46's Care Plan documents R46 is at increased risk for skin breakdown related to decreased mobility and multiple sclerosis, R46 currently has no skin impairments. Progress note dated 5/11/26 at 9:04 AM, titled Weekly Skin Assessment, created by V17 (Licensed Practical Nurse) documents 1 (OLD) 1+ edema BLE (bilateral lower extremities), chronic. Legs elevated while in bed but does not elevate during the day after she gets up, 2 (OLD) 16 Fr (French) foley catheter draining light amber colored urine at this time with minimal sediment noted in tubing resident does continue to c/o (complain of) discomfort to labia r/t (related to) catheter, no redness or open areas noted. Resident has a new order for Estradiol cream 3 times a week but states that she does not want this, she wants something that can be applied externally. Resident is often tugging on & moving tubing around while she is in bed, educated resident that this can cause friction & resident states that she is aware but is very anxious about catheter & will not leave it alone. Heels: WNL (Within Normal Limits). Bony prominences: no issues. Skin turgor: <3 (less than 3) seconds, R (right) posterior hand. Buttocks: WNL. Skin: WNL. resident tolerated assessment without c/o pain or discomfort. On 5/11/26 at 10:00 AM, R46 stated she has a urinary catheter, and she has some pain and rawness to her vagina. R46 stated a nurse hasn't looked at the rawness on her vagina in quite some time, R46 stated the nurses used to do skin checks on her but they haven't done one in a long time. R46 stated she has talked to a couple different nurses about it, and she feels like they aren't getting her the correct medicine. R46 stated she talked to V7 (Infection Preventionist), and she called the doctor and got an internal hormone cream that doesn't help, V7 stated she feels like she should have something that is external to help with the excoriation. On 5/11/26 at 10:10 AM, observed urinary catheter care on R46, completed by V5 (Certified Nursing Assistant/CNA). V5 completed R46's urinary catheter care by herself and was able to spread R46's legs by herself to clean without any issues. R46's vagina was observed to be red with some white discharge. V5 stated her vagina has been excoriated for a while now and she has notified the nurse of it each time. On 5/13/26 at 9:51 AM, V7 (Infection Preventionist) stated R46 told her that her vagina was feeling raw and R46 asked her to call her gynecologist. V7 stated she called the outside gynecologist that R46 goes to, and they said they would call her something in. V7 stated they prescribed estradiol to be given 3 times a week. V7 stated she has never assessed R46's vagina. On 5/13/26 at 10:58 AM, V9 (CNA) stated she takes care of R46 often and her vagina is chapped looking externally and R46 complains about it to her. V9 stated she had told the nurse about it before, and the nurse told her to put lubricant on it. On 5/13/26 at 3:07 PM, V17 stated R46 tells her every day that her vagina is bothering her. V17 stated at one point she had the CNA's put lubricant around the catheter tubing so maybe that would stop the tubing from rubbing her. V17 stated she called the doctor and got a new order for lidocaine cream. V17 stated the last time she observed R46's vagina was last Thursday (5/7/26). V17 stated R46 has complained about her vagina bothering her for as long as she can remember. V17 stated R46 had a uterine biopsy not long ago and they saw some discharge then, so they put her on antibiotics that ran from 4/23/26-4/30/26. On 5/14/26 at 3:05 PM, this surveyor asked V17 about a progress note from 5/11/26 at 9:04 AM that documented she did a skin check on R46. This surveyor stated to V17 that in a previous interview on 5/13/26 at 3:07 PM she told this surveyor that she last saw R46's vaginal area on the previous Thursday, which was 5/7/26 but she charted on 5/11/26 that she did a skin check on R46 and V17 documented that R46 did not have any redness to her vaginal area at that time. V17 stated she forgot about that when this surveyor interviewed her previously. V17 stated that on 5/11/26 the CNA came and got her after the CNA performed urinary catheter care and R46's bed bath that morning of 5/11/26 for her to do R46's skin check before they got her dressed and into her wheelchair. V17 stated she looked at her vaginal area and she didn't see any redness. This surveyor told V17 that this surveyor was present in R46's room from before the CNA came into R46's room to do her bed bath and urinary catheter care and this surveyor stayed for the entire time of that care and getting R46 dressed for the day then R46 was transferred into her wheelchair. This surveyor then stated to V17 that during that observation she was not present in the residents room and during that observation R46 had redness on her vagina and white discharge. V17 then responded she must have misspoken, and she went into the room before the CNA that day. V17 stated she tried to look at the R46's vaginal and groin area the best she could but one person cannot spread R46's legs apart very easily so she might have missed the excoriation. V17 stated she did the best she could. On 5/14/26 at 9:00 AM, R46 stated V17 did not come into her room and do a skin check or look at her vaginal area on 5/11/26. V17 stated it has been quite a while since a nurse has done a skin check on her or looked at her vaginal area rawness. On 5/14/26 at 10:05 AM, V3 (Assistant Director of Nursing) stated a nurse should not call the provider with a resident concern without laying eyes on the problem first. V3 stated the nurse should assess the resident prior to calling the provider. On 5/19/26 at 9:42 AM, V1 stated they do not have a policy for non-pressure related skin conditions.

Based on interview and record review the facility failed to acquire and administer medications as ordered for 1 of 5 residents (R10) reviewed for medications in the sample of 49.The findings include: R10's Face Sheet documents an admission date of 2/8/26 with the following diagnoses in part; unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance and anxiety, unspecified psychosis not due to a substance or known physiological condition, altered mental status, and cognitive communication deficit.R10's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 5, indication R10 is severely cognitively impaired.R10's Physician Order Sheet documents an order for donepezil 5mg tablet by mouth nightly with an order date of 3/3/25.R10's Physician Order Sheet documents an order for quetiapine 25mg tablet, take 12.5 mg by mouth every night at bedtime with an order date of 4/5/25.R10's April 2026 Medication Administration Record (MAR) documents R10's quetiapine 12.5mg was not administered on 4/9/26, 4/10/26, and 4/15/26. 4/9/26 documents not administered: other and 4/10/26 and 4/15/26 documents not administered: drug/item unavailable.R10's Progress Notes document on 04/09/2026 at 2:13 am, documents Scheduled message for DON (director of Nursing); unable to locate card of quetiapine 12.5 mg - per eMAR (electronic Medication Administration Record) it was delivered 4/6.R10's Progress Notes document on 04/16/2026 at 11:08am, documents (name of pharmacy) contacted r/t (related to) Seroquel (quetiapine). Pharmacy states med will be delivered tonight.R10's Progress Notes document on 04/16/2026 at 7:36pm, documents Card of 30 (half) tabs = 12.5 mg of Quetiapine in stock now in ML (memory lane) cart.R10's April Medication Administration Record (MAR) documents R10 received donepezil 5mg tab every night was not administered on 4/29/26 and 4/30/26 and documents not administered: drug/item unavailable.R10's Progress Notes document on 04/18/2026 at 11:54pm, Called pharmacy to place refill request of donepezil. Per eMAR says it was last processed 4/16, but card cannot be located in med cart. Informed med should be delivered on next pharmacy run.R10's Progress Notes document on 04/22/2026 at 11:23pm, documents Notified DON of pharmacy issue refilling Donepezil 5 mg.R10's Progress Notes document on 04/29/2026 at 9:21pm, documents Notified DON there is still pharmacy issue filling donepezil.R10's Progress Notes document on 04/30/2026, documents Spoke with (name of pharmacy) r/t donepezil. Pharmacy states it will be delivered to facility.R10's Progress Notes document on 05/01/2026 at 9:02pm, (name of pharmacy) contacted again this morning r/t donepezil. Pharmacy apologizes for delay and states med will be delivered tonight.The facility log for Emergency medication Supply (E-Kit) for the month of April was reviewed. There was no record of medication being pulled for V10.On 5/14/26 at 10:53am, V16 (Licensed Practical Nurse/LPN) stated he was not familiar off the top of his head what medication was available in the emergency medication supply. V16 stated if a medication is not in there, they are to notify the physician if the resident is going to miss a dose and they can order the medication stat through the pharmacy. V16 stated to his knowledge, there was not a backup pharmacy.On 5/14/26 at 11:01am, V17 (Licensed Practical Nurse/LPN) stated they put in a request to the pharmacy electronically for a refill. V17 stated they put in a stat order to the pharmacy for emergency needs for medication not in the emergency Medication supply.On 5/14/26 at 11:24pm, V15 (Licensed Practical Nurse/LPN) stated they do not have a backup pharmacy, they put in a request with the pharmacy for a STAT delivery. V15 stated there is no Aricept (Donepezil) in the emergency medication kit.On 5/14/26 at 3:50pm V3 (Assistant Director of Nursing) stated she has no record of staff receiving medications for R10 from any other pharmacy other than the pharmacy they are contracted with. V3 stated the facility has Seroquel in their Ekit, but not Donepezil.The facility policy titled, Medication Administration with a revision date of 2/04 documents under Objective: To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of resident.The facility policy titled Pharmaceutical Procedures with a revision date of 1/5/23 under Emergency Medication Supply documents Emergency Drugs - May be Contained in Automated Convenience Box A. A sealed emergency medication kit containing a limited range of medications for immediate use shall be located at designated areas in the facility. Any emergency medications not contained in the emergency kit shall be obtained via standard back-up procedure. B. The emergency medication kit is accessible to the nurse. Contents of the kit are to be removed only upon the physician's order to a licensed nurse authorized to administer drugs.

Based on interview and record review the facility failed to ensure a resident's rights to make treatment decision was honored for 1 or 5 (R21) residents reviewed for resident rights to make treatment decisions in the sample of 49. Findings include:R21's Face Sheet documents an admission date of 2/19/26 with included diagnoses of insomnia, bipolar disorder, and major depressive disorder. R21's MDS (Minimum Date Set) dated 3/25/26 documents a BIMS (Brief Interview of Mental Status) of 15, indicating intact cognition. Section N documents R21 is currently taking antianxiety, antidepressant, and hypnotic medications. R21's Care Plan documents R21 has insomnia, anxiety disorder, bipolar disorder, and major depressive disorder (start date 2/20/26) with interventions administer Ativan PRN (as needed) and monitor for side effects, administer duloxetine once a day as ordered and monitor for side effects including boxed warnings (start date (2/20/26), administer vilazodone at bedtime as ordered and monitor for side effect and included boxed warnings (start 2/20/26), administer zolpidem at bedtime as ordered and monitor for side effects (start 2/20/26), monitor for any changes in mood and/or behaviors related to reduction (start 2/20/26), and review medication during behavior committee meeting for gradual does reduction (start 2/20/26). R21's Physician's orders documents orders for duloxetine 60 mg (milligrams) one time a day for major depressive disorder (start date 2/19/26, end date: open-ended), vilazodone 40 mg one time a day for major depressive disorder (start date: 2/20/26, end date: open-ended), zolpidem 5 mg at bed time as needed for insomnia (start date: 2/20/26, end date: open-ended), buspirone 5 mg three times a day for bipolar disorder (start date: 5/1/26, end date: open-ended), and Ativan 0.5 mg every 8 hours as needed for anxiety disorder (start date: 5/12/26, end date 5/25/26). On 5/13/26 at 3:19 PM, R21 stated she doesn't remember anyone going over side effects or black box warnings with her for her psychiatric medications since she's been at this facility. R21 stated she signed a lot of papers when she was admitted , and she can't remember if she signed a consent then or not, but she hasn't signed any other consents since she was admitted . R21's documents titled Observation Detail List Report documents under Psychotropic Medication Consent, Completed Date: 2/20/26 at 10:01 AM and under Physician's Orders, 1. 2/20/26 duloxetine 60 mg central nervous system agents treatment for major depressive disorder. Outcome reduction in depression, 2. 2/20/26 lorazepam 0.5 mg benzodiazepine for treatment of anxiety. Outcome reduction in anxiety, and 3. 2/20/26 zolpidem 5 mg non-benzodiazepine hypnotics treatment for insomnia. Outcome reduction in sleep disturbance. Under Consent for use of medication is R21's signature. On 5/14/26 at 12:29 PM, V3 (Assistant Director of Nursing) stated they only had R21 sign a psychotropic medication consent for duloxetine, lorazepam, and zolpidem but never had R21 sign a consent for buspirone or vilazodone. V3 stated there should have been a consent signed prior to starting those medications. A facility policy titled Psychopharmacologic Drug Usage Procedure dated 10/18/17 documents under Procedure, 6. Consent for use of psychopharmacologic medications must be given in writing by the resident and/or resident's representative. This consent form will also include the educational components of name of medication, condition/reason for its use, possible risks/side effects of the medication, and expected outcome/benefits of the medication.

Based on Interview, observation, and record review the facility failed to accurately assess a resident's eating abilities for 1 of 1 resident (R60) reviewed for accuracy of assessments in a sample of 49.Findings include:R60's face sheet documents an admission date of 07/25/23 with diagnoses including: dementia, type 2 diabetes mellitus, weakness, hypertensive chronic kidney disease, vitamin B12 deficiency, anemia, hypothyroidism, spinal stenosis, and cerebral infarction.R60's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) score of 99 indicating severe cognitive impairment. R60's eating assistance is documented as setup or clean up assistance indicating helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. R60's progress note dated 03/30/2026 at 1:17 PM RD weight note. R60 has multiple diagnoses including dementia, diabetes mellitus type II, hypertension, hyperlipidemia, transient ischemic attack, cerebral infarction, and dysphagia. R60 requires assistance at meals in dining room.R60's progress note dated 05/08/2026 at 10:43 AM RD (Registered Dietitian) Quarterly note. R60 has multiple diagnoses including dementia, diabetes mellitus type II, hypertension, hyperlipidemia, transient ischemic attack, cerebral infarction, and dysphagia. R60 requires assistance at meals in dining room.R60's point of care history dated 03/01/26 - 05/14/26 documents: feeder-puree diet, nectar thick liquids, diabetic preferences.On 05/11/26 at 12:36 PM, R60 was sitting in the dining room and received assistance with his lunch.On 05/13/26 at 7:39 AM, R60's was sitting in the dining room with his breakfast sitting in front of him, R60 was making no movement to eat any of his food, at 7:52 AM staff started assisting R60 with his breakfast and R60 finished his breakfast with assistance.On 05/13/26 at 12:16 PM, R60 was in the dining room and received his lunch, at 12:21 PM staff offered R60 one bite of his food and left and delivered another lunch tray. At 12:27 PM staff assisted R60 with one more bite and walked off. At 12:41 PM staff offered R60 one more bite of his lunch and walked off. R60 took no bites of his food on his own without staff assistance. At 12:45 PM staff sat down to assist R60 with his lunch.On 05/14/26 at 12:50 PM, V14 (Minimum Data Set Coordinator) stated to determine how a resident is assessed for their eating assistance she will go back into point of care charting and review the typical needs of the resident through the lookback period and determine the residents eating abilities from there. V14 stated, if the resident has declined, if their insurance or family will pay for an evaluation, the resident would get an evaluation. If the evaluation determined the resident required the restorative program that would be initiated. V14 stated, the CNAs will also tell her if there is a resident that has for approximately three days or more appeared their eating ability has changed, she would go evaluate the resident and determine the resident's abilities.The facility policy dated 04/01/25 titled, MDS Completion documents: the purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI (Resident Assessment Instrument) manual. The facility will designate a MDS coordinator to facilitate the completion of the required assessments. Members of the IDT will complete their assigned MDS sections and corresponding CAA's (Care Area Assessments) within the specifications and timelines established by the RAI Manual guidelines.

Based on interview, observation, and record review the facility failed to provide recommended supplements and nutritional oversight to prevent further weight loss for a resident that is below normal body mass index for one (R9) of one resident reviewed for weight loss in a sample of 49.Findings include:R9's face sheet documents an admission date of 04/13/22 with diagnoses including: aphasia following cerebral infarction, latent tuberculosis, dementia, nutritional deficiency, cerebral infarction, dysphagia, anorexia nervosa, iron deficiency, diabetes mellitus, abnormal posture, and rheumatoid arthritis.R9's MDS dated [DATE] documents a BIMS score of 99 indicating severe cognitive impairment. R9's eating assistance is documented as supervision or touching assistance indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R9's physician order sheet documents a dietary order dated 09/17/24 of pureed solids with a high calorie high protein (HCHP) supplement with an end date listed as open ended.R9's care plan documents a problem are of resident care information dated 11/02/22 with interventions including: mechanical diet with pureed meats with thin liquids and a high calorie high protein supplement (no super cereal) with diabetic preferences. R9 is a 1x feeder at all meals dated 01/04/23. R9 care plan documents a problem area of nutritional status: R9 has a history of stroke with a diagnosis of aphasia, she has a diagnosis of dysphagia which puts her at risk for chewing, choking and swallowing difficulties dated 01/11/23 with interventions including: monitor for signs and symptoms of chewing, choking, or swallowing difficulties and report to speech language pathologist as needed and serve mechanical soft diet with pureed meats and thin liquids via straws. R9's care plan documents a problem area dated 05/19/22 of nutritional status: R9 has a history of weight loss, PO (per oral) intake is 25-75 % which puts her at risk for further weight loss with interventions including administer mirtazapine 7.5 mg (milligram) as ordered for appetite stimulant and monitor for side effects and obtain weights as ordered dated 01/11/23 and serve HCHP supplement per MD (medical doctor) orders. R9's care plan documents a problem area dated 05/13/22 of nutritional status: R9 has a diagnoses of dysphagia which puts her at risk for chewing, choking and swallowing difficulties with an intervention of serve pureed diet per MD orders dated 05/13/22.R9's progress note dated 02/02/26 at 10:42 AM documents: RD (Registered Dietician) annual/weight note. R9 is a recent readmission with hospital diagnoses including: septic shock, urinary tract infection, hypotension, hypoglycemia, and hypothermia. Multiple diagnoses including diabetes mellitus type II, dementia, hypertension, gastroesophageal reflux disease, iron deficiency anemia, cerebral vascular accident, aphasia, and dysphagia. R9 has contractures due to osteoarthritis and rheumatoid arthritis. R9 eats meals in her room. R9 takes megestrol which can stimulate appetite. R9's height is 65 inches and her weight on 01/29 was 86 pounds with a BMI (body mass index) of 14 which is a very low body weight. R9's weight review shows no significant weight changes at this time. R9's usual body weight is 84-90 pounds. R9 has a history of low weight/low BMI/and skin breakdown. R9 is on weekly weights. Continue R9's treatments for necrotic toes and coccyx. Continue pureed meats and dessert, HCHPS (high calorie high protein supplement), mechanical soft vegetables, thin liquids with straws, fortified pudding twice a day, ice cream twice a day, extra sauces/gravies, extra margarine/butter all meals. R9 has a history of refusing Arginaid. Encourage intakes with R9. R9 has no diabetic mellitus restrictions related to low weight and skin breakdown. Monitor R9's weights and skin and refer as needed.R9's vitals documents R9 weight on 03/24/26 at 7:21 AM was 91.3 pounds, R9's weight on 04/08/26 at 6:12 AM was 92.3 pounds, and 05/08/26 at 11:38 AM was 95.2 pounds with a BMI of 15.84%.On 05/11/26 at 12:41 PM, R9 received her lunch in her room, at 1:04 PM R9 was in her room by herself with her lunch in front of her with R9 sleeping and no food eaten. During this time there were continuous observations made of anyone going into or coming out of R9's room from the hallway. No staff were seen going into R9's room providing encouragement or providing assistant after R9's tray was dropped off. R9 did not receive any fortified pudding or ice cream with her meal.R9's meal ticket dated 05/13/26 documents: regular diet with pureed texture, diet other: HCHP supplement, beverages as prune juice 8 fluid ounces and fortified whole milk 8 ounces. Under the notes section documents: all pureed meats, extra margarine/butter all meals and extra sauces/gravies all meals.On 05/13/26 at 7:43 AM, R9 received her breakfast in her room, at 8:04 AM R9 was in her room with her breakfast in front of her and no food had been eaten, at 8:30 AM R9's food was still in front of her and no food had been eaten. During this time there were continuous observations made of anyone going into or coming out of R9's room from the hallway. No staff were seen going into R9's room providing encouragement or providing assistant after R9's tray was dropped off. R9 did not receive any fortified milk with her breakfast.On 05/13/26 at 12:21 PM, R9 received her lunch in her room, at 12:55 PM R9 was slowly eating a few bites of her food in her room by herself, R9 had approximately 25% of her food eaten with about four drips of food on the towel covering her chest area. R9 did not receive any fortified pudding or any ice cream with her lunch.On 05/14/26 at 7:45 AM R9, received her breakfast, at 7:49 AM R9 was in her room by herself with her food in front of her, surveyor stopped and asked how her food was and R9 looked down at her arm which was covered by a sheet, and asked if she could get some help. Surveyor was under the impression R9 wanted the blanket off of her hand and wrist so she could eat, so surveyor moved the blanket. R9's hand was very contracted and R9 was struggling with the spoon. R9 asked if she could get some help again, surveyor confirmed R9 wanted assistance eating and went and told a Certified Nurse Aide (CNA) R9 wanted some assistance.On 05/14/26 at 7:48 AM V28 (Certified Nurse Aide) stated, R9 typically does not want help.R9's meal ticket dated 05/14/26 lunch documents: regular diet with pureed texture, HCHP supplement. Food adds lists fortified pudding 4 ounces and fortified whole milk 8 ounces, under the notes section lists: all pureed meats, extra margarine/butter all meals, extra sauces/gravies all meals.On 05/14/26 at 12:30 PM, R9 already had her food in her room. At 12:34 PM R9 was eating in her room by herself and struggling with her spoon. R9's spoon was at an approximate 80 degree angle and when R9 would get food onto the spoon, by the time she would get it to her mouth most of the food would fall off the spoon. At 12:42 PM R9 was still in her room by herself eating, R9 had gotten her spoon positioned better and was able to get a normal size bite. At 12:50 PM R9 had eaten approximately 0.33 percent of her food. R9 did not receive any ice cream with her lunch.On 05/14/26 at 1:25 PM, V23 (Dietary Manager) stated he does not know why all the supplements would not be given to R9. V23 stated he does not know why the meal tickets would not match the Registered Dietician recommendations or the physician orders, he would have to check.On 05/14/26 at 3:05 PM, V1(Administrator) stated, residents should have been assisted with their silverware, if due to their diagnosis such as dementia or contractures they are unable to or struggle. V1 stated, those items should all be care planned for the resident. V1 stated, if a resident was not eating she would expect staff within a few minutes to five minutes at most to encourage, cue, or assist that resident with eating. V1 stated, even if a resident typically does not want assistance, if they require assistance they should always be asked if they would like any assistance.The policy dated 02/04 titled, Feeding Assistance 3. Assist resident to a comfortable position 4. Tuck the napkin under the chin, 6. Feed resident slowly with fork or spoon, filled only half full 11. Record intake as required 12. Eating difficulties or lack of appetite should be reported to the physician.The policy dated 06/2010 with the title, Liberalized Diets documents: purpose: Increase ability to maintain acceptable weight and nutritional status, and improve, and improve quality of life for residents, improve residents nutritional status, improve dietary compliance, enhance caloric and nutrient intake and ultimately increase resident satisfaction. J. Hi Calorie/Hi protein Supplement: If a resident begins to lose weight, their intake will be evaluated and this meal pattern will be adjusted to increase caloric and nutrients. A variety of additional nutritional foods may be added to the meal, or between meal nourishment's / supplements may be offered. If it is difficult to facilitate sufficient calorie and / or protein intake at meal times, physician may order hi calorie / hi protein supplement per dietary discretion. Dietary will follow the hi calorie / hi protein supplement policy and procedure.

Based on observation, interview, and record review the facility failed to respect resident choices for 1 of 1 (R11) resident reviewed for self-determination in a sample of 49. Findings include:R11's Face Sheet documents an admission date of 4/23/26 with included diagnoses of pain, unsteadiness on feet, edema, weakness, restless leg syndrome, and left knee primary osteoarthritis. R11's MDS (Minimum Data Set) dated 4/30/26 documents a BIMS (Brief Interview of Mental Status) of 14, indicating intact cognition. Section J documents under Pain Assessment Interview that R11 has had frequent pain or hurting in the last 5 days and it occasionally effects R11's sleep and occasionally interferes with therapy activities. On 5/11/2026 at 11:27 AM, R11 was observed in her room crying and shaking. R11 stated she just walked with PT (Physical Therapy) and her legs are hurting her. R11 stated she wanted to lay down, but a CNA (Certified Nursing Aide) told her she couldn't lay down even though her therapist told her she could. R11 pressed her call light to ask to be put in bed and V4 (CNA) answered the call light and told R11 that she thought she had one more therapy session and then lunch so she couldn't lay down until after that. R11 told V4 that she walked a long distance with therapy this morning and was very tired and her legs were hurting. V4 then told this surveyor that they do not lay residents down on this hallway before lunch because they are there to rehab to go home and need to be up. V4 stated she would tell the nurse she was in pain. On 5/13/26 at 10:48 AM, V8 (Licensed Practical Nurse) stated R11 takes pain medicine as needed, and she does ask for it often. V8 stated R11's son told her that she has had generalized pain for a long time at home prior to coming to the facility. V8 stated if R11 asked to be laid down, she could be laid down at any time during the day. V8 stated they don't make residents stay up in the mornings on R11's hallway, they can lay down anytime they want as long as they participate in their therapy at some point in the day. V8 stated sometimes therapy is in the morning and sometimes it's in the afternoon, it is different every day and for each resident based on the therapists schedule for the day. On 5/17/26 at 8:51 AM, V27 (Physical Therapy Assistant) stated she walked R11 the morning of 5/11/26 and she walked her pretty early in the morning because she was up and ready earlier than she usually is. V27 stated R11 walked a good distance that morning. V27 stated if R11 wanted to lay down after her therapy session that morning and before the next therapy session she can. Residents lay down and rest all the time between sessions, no matter what time of day it is. On 5/14/26 at 10:05 AM, V2 (Assistant Director of Nursing) stated if a resident asks to lay down, they can lay down, no matter what time of day it is. A facility policy titled Resident Rights dated 11/28/17 documents under F561 Self-Determination, The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

Based on interview and record review the facility failed to timely removed a urinary catheter and timely test/flush a urinary catheter as required for 2 of 4 (R12, R18) residents reviewed for urinary catheter care in a sample of 49.Findings include:1. R18's Face Sheet documents an admission date of 5/5/26 with included diagnoses of dementia. R18's MDS (Minimum Data Set) dated 5/8/26 documents a BIMS (Brief Interview of Mental Status) of 99, indicating the assessment was unable to be performed. R18's Care Plan documents R18 has an indwelling urinary catheter related to diagnoses of urine retention. R18's Discharge Summary from local hospital dated 5/5/26 documents R18 is experiencing urinary retention during this hospital stay and required straight catheterization several times, urinary catheter placed 5/5/26. On 05/11/2026 at 11:33 AM, R18 was noted propelling herself in the hallway and her urinary catheter bag was hanging under her wheelchair with no privacy bag on it. R18's catheter bag and catheter tubing were dragging the ground. R18 was observed to roll over the drainage bag while propelling. On 5/13/26 at 4:04 PM, V3 (Assistant Director of Nursing) stated R18 was admitted from the hospital with a urinary catheter, and she had some urine retention while at the hospital that was not something she had prior to the hospital. V3 stated R18 should have had her urinary catheter pulled already and started on bladder training because R18 does not have the proper diagnoses to have a urinary catheter in this facility. R18 stated usually V10 (Nurse Practitioner) catches that a resident has a urinary catheter still when they shouldn't after being admitted from the hospital and she would have them pull it and start bladder training. V3 stated even though V10 hasn't caught it, the MDS nurse, Admissions nurse, or floor nurse should have caught that R18 still had a urinary catheter and should have brought it to the providers attention so they could get an order to pull it and start bladder training. V3 stated R18 does not have a urology appointment scheduled. On 5/18/26 at 8:39 AM, V1 (Administrator) stated they do not have specific policy for urinary catheter just the procedure for care. 2. R12's face sheet documents an admission date of 08/30/22 with diagnoses including: chronic kidney disease and obstructive and reflux uropathy. R12's Minimum Data Sheet (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 14 indicating R12 is cognitively intact. R12's care plan documents a problem area of indwelling catheter dated 05/06/24 with interventions including: change catheter and drainage bag as ordered/needed and provide catheter care as needed both dated 05/06/24. On 05/12/26 at 7:39 AM, R12 stated she does not feel good she cannot eat. R12 stated, it feels like her bladder is going to burst, her catheter is clogged and she hasn't had any urine removed from her bladder since last night. R12 stated, she told the Certified Nurse Aide (CNA) that it was clogged last night and they haven't fixed it yet, so it is still clogged this morning. On 05/12/26 at 7:41 AM, V12 (Licensed Practical Nurse) stated, he was unaware that R12's catheter was clogged and he will go check on her. On 05/13/26 at 11:05AM, R12 refused to let staff and surveyor observed indwelling catheter care. On 05/13/26 at 11:06AM, R12 stated she was in pain all last night. R12 said they came in this morning and finally changed the catheter this morning. R12 stated, she doesn't want anyone touching her catheter she just now got it where it was draining finally and she doesn't want to mess it up. R12 stated, they did come in this morning and flush the catheter to try to get it to work, because it wasn't draining any urine out of the catheter and that was what was causing her pain. On 05/13/26 at 11:11AM, V12 stated, he changed R12's catheter today around 8:00 AM. V12 stated a CNA and the surveyor came and told him R12 was having pain and the catheter wasn't draining. V12 stated, R12 had stated her catheter was clogged. V12 stated, he didn't get any report from night shift reporting R12 was having any problems with pain or her indwelling catheter was not draining probably. V12 stated, when he went to change the indwelling catheter he noticed there was maybe around 100 milliliters of urine in the collection bag. V12 stated, the catheter was full of mucous and that was probably what was clogging the catheter. V12 stated, he did let hospice know about the catheter clogging. V12 stated, he did let hospice know about him changing R12's catheter. V12 stated, hospice was aware of R12 having problems with having mucous in R12 catheter. V12 stated, R12's indwelling catheter wasn't draining correctly last month and they ended up changing the catheter on 04/21/26 and it wasn't due to be changed until 04/25/26. R12's urine output documentation for 04/14/26 to 05/14/26 only documents urine output on 05/08/26 at 1:52 PM R12 with 600 milliliters (ml)of urine output and 05/14/26 at 1:54 PM with 1000 ml of urine output. On 05/13/26 at 9:48 AM, V7 (Infection Preventionist) stated CNAs document urine output under vitals and whatever is there is what they have. V7 stated, the CNAs should be documenting the urine output every time the bag is emptied. On 05/14/26 at 9:30 AM, V3 (Assistant Director of Nursing) stated if a resident tells a CNA they think their catheter is clogged, the CNA should tell the nurse and the nurse should assess the resident's catheter including: test, flush, change, whatever is needed. V3 stated, her expectation of a time frame for the nurse would be approximately 10 -15 minutes, definitely not overnight. The policy dated 06/05 titled, Catheter Care documents 9. observe condition of resident's skin and report any significant findings to the nurse.

Based on observation, interview, and record review, the facility failed to ensure a safe resident environment and protection from physical abuse for 1(R4) of 3 residents reviewed for resident-to-resident abuse in the sample of 9. This failure resulted in R4 being bitten on the hand by R2, leaving a bruise. A reasonable person being bitten would feel fearful, threatened and intimidated. R4's admission Record dated 3/4/26 documents an admission date of 4/20/23 and included diagnoses of dementia, traumatic subdural hemorrhage, cognitive communication deficit, and vascular dementia. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 4, indicating R4 has severe cognitive impairment. R4's Care Plan with last revision date of 2/18/26 documents a Problem Category of Mood State (start date 4/24/23) documenting R4 has major depressive disorder and anxiety. R4 has a history of trauma (sexual and other forms of abuse). The Long-Term Care Facility Serious Injury Incident Report documented an incident date of 2/14/26 at 1:54PM and is marked as the final report. The incident category is marked Resident to Resident Altercation and lists R2 and R4 as the residents involved. Both residents are marked as interviewable and capable of communication, but unable to make informed decisions. R3 is listed as a witness to the incident. The detailed incident summary documents On 2/14/2026 at approximately 13:54 (1:54PM), R4 was going through her closet when she was approached by R2 about taking her boyfriend. R4 started yelling that she doesn't want her boyfriend when R2 grabbed R4's hand and bit it. Residents were immediately separated and calmed down. Body assessment was done and R4 has a bruise to the top of her left hand. POA's (Power of Attorneys) and MD's (Medical Doctors) were notified. Both residents will continue to be under close monitoring for any further behaviors and redirected while engaging in separate activity events. An event report for R2 dated 2/14/26 at 1:54 PM documents Notified on call et (and) facility administrator as follows: Res (resident) roommate (R4) sitting in w/c (wheelchair) near closet in their room. This Res (R2) started to raise voice et hit with open fist towards roommate. Bystander nearby called for CNA (Certified Nurse Aide) staff to report fight. This Resident (R2) bit other Res (R4) to L (left) hand causing injury to other Res hand. CNA staff able to separate both residents. This resident is in room. Notified PCP (primary care physician) et POA (Power of Attorney). Awaiting further instructions. Interviews were attempted with R2, R3 and R4 during the survey, but due to all three residents' level of cognition, they were unable to recall the incident or what occurred. R4's Progress Note, authored by V26 (Licensed Practical Nurse/LPN) dated 2/14/26 at 2:03 PM documents, R4 was sitting in her room with R2 when a verbal argument escalated into a physical assault in which R2 bit R4 on the right hand causing bruising that was immediately visible. On 3/2/26 at 2:21 PM, R4 was observed to have a crescent shaped dark purple almost black linear bruise to palmar surface of R4's right hand below the 5th finger. There were no signs or symptoms of infection or slow healing. The crescent moon shaped bruise resembled the outline of a human bite mark. On 3/2/26 at 3:21 PM, V7 (CNA) stated she did not witness R2 bite R4 on the hand on the 14th of February. V7 stated she and another CNA heard a resident (R3) yelling that someone was fighting. V7 stated she does not remember the exact time, but it was after lunch between approximately 12:00 PM and 1:00 PM. V7 stated, We ran down to their (R2 and R4's) room and R4 was still in her closet and R2 was on the other side of the room. R4 was holding her hand and said, 'She bit me,' meaning R2. V7 stated R4 told her initially the bite did not hurt. V7 stated she wheeled R4 up to the nurse's station for evaluation and treatment by the nurse. V7 stated by the time she had entered the room, R2 and R4 had separated. V7 stated R4 did have a bite mark with bruising on her right hand. V7 stated the injury was closed, the skin was not broken. V7 stated R2 and R4 don't frequently fight but usually get along. V7 stated she is not sure exactly what caused the altercation to begin with. V7 stated she did remember when walking into the room R4 stating, I don't want her man repeatedly. On 3/2/26 at 3:31 PM, V8 (CNA) stated she was doing rounds on 2/14/24 a little after lunch time when she heard screaming from the other side of the unit. V8 stated, So I sprinted down there, and they (R2 and R4) were already separated by the time I got there. When I walked in the room R2 was wheeling herself back to her bed and R4 was facing us (staff) wheeling herself toward the door. R4 was holding out her hand and I saw a blood blister on the palm side, and when I asked what happened she (R4) stated, 'She (R2) bit me.' V8 stated there also appeared to be lipstick around the bite area. V8 stated R2 refused to speak to them or the nurse and tell them what happened. V8 stated the wound in question to R4's right hand appeared to be in a crescent moon shape that looked like a human bite. On 3/2/26 at 3:42 PM, V26 (LPN) stated she remembers the incident between R2 and R4 on 2/14/24. V26 stated she remembered hearing yelling and one of the other residents stated they were fighting in there, meaning R2 and R4's room. V26 stated one of the CNAs (she said she didn't remember who) said R2 bit R4 on the hand. V26 stated the CNA's got the two residents separated and brought R4 to her for evaluation and treatment. V26 stated R4 kept telling her that her right hand was hurting. V26 stated when she looked at R4's right hand it had a bruise on the palmar side in the shape of a human bite or crescent moon. V26 stated the skin wasn't broken. V26 stated she immediately notified R4's primary physician who said to clean the area and put a dry bandage over it. V26 stated she then notified V1 (Administrator) and both residents' power of attorneys and the on-call nurse manager. On 3/5/26 at 9:10 AM, V23 (Memory Care Director) stated she was not here the day of the alleged assault of R4 by R2. V23 stated she was notified shortly after by telephone that the alleged assault had occurred. V23 stated she gave instructions for staff to monitor R2 the rest of the day until bedtime. V23 stated R2 was already on special frequent checks due to her recent uptick in behaviors and agitation. V23 also stated R2 is care planned for behaviors as well and has a sticker on her door to notify staff she is to be checked on frequently and to track her behaviors in the electronic health record (EHR). V23 stated the day she returned to work she also started tracking R4's mood for a few days to make sure she wasn't acting depressed, scared or anxious in any way after the alleged assault, and she stated R4 did not. V23 stated the reason a room change wasn't instituted for either R2 or R4 was because both residents have dementia, and a room change risked increasing confusion and agitation for one or both. V23 also stated R4 was pointedly asked and rechecked frequently to see if she was afraid, and she denied that she was. V23 stated with the information above, the facility administration staff thought it was best to leave them as roommates. V23 stated R2 has not had any episodes like this before or after this event directed towards R4 or any other residents. V23 stated she believes overall R4 is safe. On 3/5/26 at 1:28 PM, V1 (Administrator) stated she was notified of the alleged assault of R4 by R2 right after it happened because she remembers it being early afternoon. V1 stated she was informed that R4 didn't show any signs of fear even immediately after the incident. V1 stated she verified R2 and R4 were immediately separated and put into separate activities. V1 stated R2 and R4 were monitored closely that evening, and due to R4 not showing any signs of fear and R2 not showing any more signs of aggression, the facility administration chose not to make a room change because sometimes that can increase confusion and agitation. V1 stated she believed there was nothing the facility could have done to prevent the incident. V1 stated R2 had never shown aggression in the past to her peers, so this was unexpected. V1 stated she also believed facility staff handled the incident appropriately. The facility's abuse policy dated revised 11/28/19 documents, The facility actively prohibits resident abuse. Same policy documents, Special attention will be given to identifying behavior that increases the resident's potential for abusing self or others or being the victim of abuse.

Based on observations, interviews, and record reviews, the facility failed to follow physicians' orders, provide interventions and monitor residents at risk for pressure ulcers for 3 or 3 residents (R1, R2 and R6) reviewed for pressure ulcers in the sample of 6. This failure resulted in R1 acquiring 3 stage II pressure ulcers. The findings include:1.R1's Face Sheet documents an admission date of 6/23/2022 and includes diagnoses of Chronic Pulmonary Edema, Type 2 Diabetes Mellitus, Local Infection of the skin and Subcutaneous Tissue, Thyroiditis, Hyperlipidemia, Hypertension, Insomnia, and Chronic Atrial Fibrillation. R1's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 15 suggesting R1's cognition is intact. Section GG-Functional Abilities documents R1 requires Substantial/Maximal assistance with toileting hygiene, rolling left to right (the ability to roll from lying on back to left and right side, and then return to lying on back on the bed). R1 requires partial/moderate assistance with sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, tub/shower transfer. Section H- Bladder and Bowel documents R1 is occasionally incontinent of urine, and bowel. Section M- Skin Conditions documents R1 is at risk for pressure sores. Document shows R1 has a pressure reducing device for chair and bed.R1's care plan documents he is at increased risk for pressure ulcers and skin breakdown related to decreased mobility, generalized muscle weakness, history of pressure ulcers and diabetes. R1 prefers to stay in bed most of the day. R1 currently has boggy heels, shearing to his buttocks, MASD (Moisture Associated Skin Disorder) to the underside of penis, shearing to his lower abdominal fold, and an open area to the underside of his left nipple. Problem starts on the date 6/27/2022, and last revision on 2/3/2026. Interventions are to assess nails, treatment to bilateral heels, treatment to shearing of lower abdominal fold as ordered, treatment to shearing buttocks as ordered, treatment to peri area as ordered, comfort glide, low air loss mattress, serve high protein supplement per physician orders, encourage to protect upper extremities during therapy as tolerated. Assist resident with turning and repositioning, provide incontinent care after each incontinent episode, and side rails/enablers to assist with turning and positioning. R1's Physician Orders documents on 8/27/2024-open ended for apply skin prep to bilateral heels twice daily. On 9/10/2025-open ended document shows order for cleanse buttock region gently with Normal Saline or wound cleanser. Pat dry. Apply Triad cream to bilateral buttocks and coccyx to shearing twice a day. Apply non adherent dressing as needed for bleeding. Antifungal (Miconazole nitrate) powder 2% twice a day, apply antifungal powder to area (MASD) and shearing to scrotum and penis area, order date 10/8/2024-open ended. Off- loading boots as tolerated twice a day 6:00AM-6:00PM and 6:00PM-6:00AM, dated 9/27/2024-open ended.R1's Braden Scale for Predicting Pressure Sore Risk documents on 12/17/2025 a score of 18.0 indicating R1 is At Risk for predicting pressure sore. R1's Braden Scale dated 1/8/2026 documents a score of 17 At Risk. R1's Braden Scale dated 1/29/2026 documents a score of 15 At Risk. On 2/4/2026 at 10:45AM, R1 was observed sitting up in recliner with a pressure relieving cushion in the chair. Call light was within reach. R1 was watching television. R1 was alert and oriented and stated he was waiting for therapy to get him to go to the gym. R1 stated he thinks his care is quite good. R1 stated he hasn't been getting his showers due to the sores he has on his butt. R1 stated, I got sores because I sit or lay around too much. R1 stated he had the air mattress on his bed for a long time even before he got the sores. R1 stated he also has had a pad in his recliner for a long time as well. R1 was asked if he was able to reposition himself while in the recliner and R1 stated, no and I can't reposition myself in the bed either. R1 was asked if the staff comes in to reposition him while he is in the chair and R1 stated, 'No. R1 was asked if they reposition him while he is in bed and R1 stated usually if I am in the bed during the day which I am sometimes, they will come and help reposition me but during the night they only come and help me reposition if I ask and sometimes that is just a couple of times through the night if I wake up. Offloading boots were not in place at this time. R1 refused to let this surveyor observe his bilateral heels.On 2/5/2026 at 10:50AM Observation of peri care was performed on R1 by V4 (Certified Nurse Aide/CNA) and V11 (CNA). During peri care V4 pulled back the foreskin of the penis and R1's penis was noted to be very red with a white like paste which was difficult to remove during cleaning. During peri care noted R1's buttocks did not have a dressing to areas on buttocks. R1 had 2 noted open areas to the right buttocks and 1 open area the intergluteal cleft. Areas were cleaned during peri care. R1's buttock was noted to be red with flaky skin noted over a large part of the buttocks. Open areas to the buttocks were noted to be bleeding as blood was also noted on the pad that R1 was lying on. Offloading boots were not present at the time of this observation.On 2/5/2026 at 11:05AM, V12 Licensed Practical Nurse (LPN) and V13 (Registered Nurse/ RN) entered the room to do the treatments on R1. V12 was asked who measured the wounds, V12 stated there are 2 wound nurses that measure the wounds but when they are both off, she measures when the measurements are due. V12 was asked if she knew if the 3 open areas to R1's right buttocks had been measured and V12 stated she would have to check and see. All 3 open areas were noted to be Stage 2 areas with partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed of the wounds were pink/red with slight bleeding noted. R1 also had 1 open area (long slit) noted to the intergluteal cleft and 2 open areas to right buttocks (medial and lateral right buttocks). The left buttock was noted to have flaky skin on entire left buttocks. V12 cleansed open areas to R1's right buttocks with wound cleanser, areas were patted dry, then Triad ointment was applied to open areas and surrounding areas and covered with a foam border gauze. V12 had powder in a cup to apply to R1's penis but R1 stated he likes the ointment best. A tub of ointment was noted on R1's bedside table. V13 handed the tub to V12 with the tub label of Diaper Rash Cream and contained Zinc Oxide. V12 applied to R1's penis and groin area. R1 was noted to be on an air loss mattress. No skin prep application was observed for bilateral heels and offloading boots were not applied.The facility policy titled Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol revised 10/16/2024, documents under Sages of Pressure Injury Definitions a stage 2 pressure ulcer is Partial thickness loss of skin with exposed dermis presenting as a shallow open ulcer with a red/pink wound bed (without slough, eschar, or granulation tissue). May also present as an intact or open/ruptured serum filled blister.R1's Progress notes documents on 2/5/2026 at 10:04AM, V20 Nurse Practitioner (NP) updated on possible deterioration of buttocks wound. NP stated to retain current treatment orders, and she will assess tomorrow in person. Authored by V2 (Director of Nursing).R1's progress notes dated 2/5/2026 at 11:18 AM, V12 documented NP contacted to ask for treatment replacement for antifungal powder. Residents' family brought Diaper rash cream with Zinc in it for resident, he stated that it works better than the powder. NP ok with treatment change and with resident having access at bedside.On 2/5/2026 at 12:00PM reviewed document titled Facility Wound Summary Report dated 10/1/2025-2/4/2026. R1's wounds were not present on this wound report.On 2/5/2026 at 12:30PM, V2 was asked why R1's wounds were not on the Facility Wound Summary Report, V2 stated, I believe R1's wounds are shears so we don't measure those. V2 was asked how they monitor shears, V2 stated, we look at weekly skin notes. V2 was asked if it is acceptable to use over the counter ointments on skin issues without a physician's order, V2 stated no that is not acceptable. V2 was asked if they had a policy for turning and repositioning and V2 stated no. V2 was asked if there was documentation of R1's turn and repositioning and V2 stated no we do not document that, we just follow the standard which is turn and reposition every 2 hours.R1's Weekly skin assessment dated [DATE] at 2:04AM documents 3) Bilateral shearing to buttock remains. No bleeding observed at this time. Cleansed and Triad applied per order. 2) Heels remain boggy bilaterally. Treatment in place at this time and administered. Authored by V19. R1's weekly skin assessment dated [DATE] at 12:11AM 1) Shearing to buttocks remains bilaterally. Mild bleeding noted. New dressings applied. Treatment continues. 2) Boggy heels bilaterally remain. Sure- Prep applied per treatment. Authored by V19 Licensed Practical Nurse (LPN).R1's weekly skin assessment dated [DATE] at 6:15PM (readmission Skin Assessment) 1) moderate shearing present to bilateral buttocks. No bleeding noted, no signs and symptoms of infection noted. Area cleansed and Zinc applied as ordered. 2) Bilateral heels boggy, sure prep applied as ordered. Authored by V18 RN. R1's documents titled Resident Progress Notes documents on 2/3/2026 at 6:22AM Weekly Skin Assessment 1) moderate shearing to bilateral buttocks. No bleeding and signs or symptoms of infection. Area cleansed. Zinc applied. 2) Bilateral heels boggy. Sure- Prep applied as ordered. Authored by V17 Registered Nurse (RN). R1's Progress Notes document that R1 was sent to the ER (Emergency Room) on 1/13/26 and R1 returned from the hospital on 1/28/26. was hospitalized from [DATE]-[DATE].R1's document titled Wound Management Detail Report date /time identified 2/5/2026 at 1:48PM R1's Right Lateral Buttocks, unspecified ulcer, measuring 0.4cm (Centimeter) L(Length) x 0.5 cm W (Width). Right Meidal Buttocks, date/time identified 2/5/206 at 1:47PM unspecified ulcer, measuring 0.4cm L x 0.5 cm W. Coccyx Intergluteal cleft, date/time identified 2/5/2026 at 1:43PM unspecified ulcer, measuring 2.5cm L x 0.4cm W with light exudate of serous drainage, tissue type epithelial. 2. R2's document titled Face Sheet documents admission date of 5/12/2022 and includes Chronic Atrial Fibrillation, Osteoarthritis, Anemia, Essential Hypertension, History of Transient Ischemic Attack (TIA), and Sleep Apnea.R2's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 15 suggesting R2's cognition is intact. Section GG -Functional Abilities documents R2 depends on staff for showers/baths, lower body dressing, putting on and taking off footwear, sit to stand, chair/bed-chair transfer, and toilet transfer. R2 requires substantial/maximal assistance with lying to sitting on side of bed and sitting to lying. R2 requires partial/moderate assistance with upper body dressing and roll left to right. Section H-Bladder and Bowel documents R2 is occasionally incontinent of bladder and bowel. Section M- Skin Condition documents R2 is at risk for developing pressure ulcers/injuries. R2 has pressure relieving devices for chair and bed.R2's care plan dated 5/12/2022, documents R2 is at increased risk for pressure ulcers and skin breakdown related to decreased mobility, chronic atrial fibrillation, osteoarthritis, history of stroke, anorexia, anemia, and incontinence. Interventions include applying skin prep to bilateral heels twice daily, off-loading boots in place as ordered, assisting in turning and repositioning, providing incontinence care after each episode.R2's Physician Order report dated 2/4/2026 documents orders for Apply skin prep to bilateral heels twice a day, order date of 10/9/2024. Ensure off-loading boots are in place to bilateral lower extremities as tolerated twice a day 6:00AM-6:00PM and 6:00PM-6:00AM, order date 10/28/2025.R2's Treatment Administration Record documents order for Ensure off-loading boots are in place to bilateral lower extremities as tolerated twice a day 6AM-6PM and 6PM-6AM. Reviewed 1/5/2026-2/4/2026 with several entries of refusal to wear boots.R2's Braden Scale for Predicting Pressure Sore Risk documents 6/23/2025 with score of 15.0= At Risk. On 8/4/2025 score of 14.0 = Moderate Risk, and 11/4/2025 score of 10 = At High Risk.Document titled Facility Wound Summary does not have R2 on the log for the bilateral boggy heels.R2's Resident Progress Notes documents 1/21/2026 at 6:36PM 1) bilateral boggy heels. Authored by V6. On 1/28/2026 at 6:13PM 1) bilateral heels remain boggy. Sure prep applied as ordered. No open areas noted. Continue to monitor. Authored by V21 LPN. On 2/4/2026 at 2:45PM 1) bilateral boggy heels, authored by V6 LPN. On 2/4/2026 at 11:05AM, R2 was observed sitting up in room in a wheelchair. R2 was alert and oriented. R2 had regular shoes on and feet resting on foot pedals of wheelchair. Offloading boots were not in place. R2 stated I am just relaxing here waiting for lunch.On 2/5/2026 at 6:17AM, Observed R2 did not have bilateral boots while in bed, bilateral heels were very red. R2 had no footwear on at the time of observation.On 2/5/2026 at 12:25PM, R2 was asked if she ever wore her boots on her feet. R2 laughed and stated, I may have had one boot on one time. R2 was asked if she refuses to wear the boots, R2 stated I believe I have only had 1 boot on 1 time; nobody ever offers or tries to put my boot on. R2 stated I can tell you where to find the boot, it is in my closet where it always stays. R2 stated I haven't worn that boot in a long time, nobody has tried to put it on and I sure can't put it on myself. R2's closet was checked and one blue pressure relieving boot was noted lying in the bottom of the closet. R2 was asked where the other boot was and R2 stated I have only ever seen 1 boot.On 2/5/2026 at 1:30PM, R2 was observed lying in bed. No boots were noted to R2's bilateral feet. V13 was sitting at the nurse's station and was asked to go to R2's room to assist with assessment of R2's heels. V13 went to R2's room V13 assessed both heels and stated, the left heel is really soft and boggy, and the right one is not so bad but is more boggy on the outer aspect of the heel, left heel is non-blanchable. Boots were not applied at this time after the assessment. V13 stated he had not seen boots on R2.On 2/5/2026 at 2:45PM, V2 was asked if he expects staff to apply offloading boots to residents with orders and are at risk for pressure ulcers, V2 stated, yes I do but sometimes they refuse to wear them.On 2/6/2026 at 11:31AM, V15 (R2's Daughter) was asked if she has ever seen boots (pressure relieving) on R2 and V15 stated she has never seen any type of boots on R2. V15 stated she was not aware that R1 was supposed to have special boots on.On 2/6/2026 at 12:55PM, V16 Physician was asked if he expected the staff to follow physician orders, V16 stated yes I do. V16 was asked if he feels that offloading boots prevent heel wounds and/or help the healing process of current heel wounds. V16 stated in theory yes, the boots do help prevent and enhance healing. V16 stated he feels like the offloading boots are automatically accumulated on orders maybe for residents that meet the criteria for them. V16 stated he knows the facility has several residents that have orders for boots. V16 stated he was not aware of any residents not wearing their boots and he knows the facility has a lot of residents with orders for the boots.3. R6's document titled Face Sheet documents an admission date of 10/7/2025 and includes diagnoses of Acute Cystitis without Hematuria, Dementia, Type Diabetes Mellitus, Urinary Retention, Generalized Anxiety, Epilepsy, Major Depressive Disorder, and Mixed Hyperlipidemia.R6's Minimum data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 13 suggesting R6's cognition is intact. Section GG -Functional Abilities documents R6 requires Partial/moderate assistance with toileting hygiene, lower body dressing, rolling left to right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), lying on the side of the bed, tub/shower transfer. R6 requires substantial assistance with shower/bathing, putting on/taking off footwear, sit to stand, chair/bed-to-chair transfers, toilet transfers. Section H-Bladder and Bowel show R6 is occasionally incontinent of bowel and R6 has an indwelling catheter for urination. Section M-Skin Conditions documents R6 is at risk of developing pressure ulcers/injuries. Document shows R6 has 1 unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar, and 1 unstageable deep tissue injury.R6's care plan documents R6 is at increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness following recent illness and hospitalization, dementia, humerus fracture, diabetes, major depression disorder, and generalized anxiety disorder. R6 currently has a pressure injury to her left heel, edema to her left upper extremity, and a pressure injury to left buttocks. Problem start date was 10/7/2025. Approach includes: 12/26/2025 treatment to pressure injury of left buttocks, 10/27/2025 off-loading boot in place as tolerated, 10/17/2025 treatment to pressure injury to left heel as ordered,10/7/2025 assist in turning and repositioning, 10/7/2025 pressure reducing device in wheelchair and bed.Physician Order Report dated 2/5/2026 shows orders for wounds as follows: Deep Tissue Injury (DTI) to buttocks; cleanse with Normal Saline or wound cleanser, pat dry, apply Zinc and border foam dressing daily, dated 1/2/2026. Left Heel, cleanse with wound cleanser and pat dry. Apply Medi honey to wound bed. Cover with gauze and ABD pad, wrap with gauze and secure with tape daily, dated 1/8/26. Offloading boots in place as tolerated twice a day 6:00AM-6:00PM and 6:00PM-6:00AM dated 10/28/2025. R6 Braden Scale for Predicting Pressure Sore Risk documents: 10/8/2025 score 22.0 Not at Risk, 10/21/2025= 17.0 At Risk, 10/31/2025=17.0 At Risk.Document titled Facility Wound Summary documents R6 has a Pressure Ulcer unstageable-slough and or eschar with date identified 10/22/2025 to left heel. Wound was not present upon admission, initial size as 2cm L x 4.8cm W, and current size 1.5cm L x 1.7cm W. On 2/4/2026 at 1:52AM, R6 was observed resting in bed. R6 stated she has a wound to her foot. R6 did not have an off-loading boot in place at the time of observation. R6 stated she gets help with turning and repositioning sometimes on nights, not always every 2 hours and she is up a lot in her wheelchair during the day.On 2/5/2026 at 1:50PM, R6 was resting in bed. R6 did not have a pressure-relieving boot on her left foot as ordered. On 2/5/2026 at 3:17PM, R6 was sitting up in wheelchair in the dining room. R6 was asked privately about her wounds that were documented to left buttocks and left heel. R6 was asked if she understood how she acquired these wounds and R6 stated, Yes I know, it is because I sit up in this wheelchair all day long somedays. R6 was asked if she was repositioned in the wheelchair throughout the day and R6 stated, no not while I am in the wheelchair. R6 was noted to have a dressing to the left heel with gauze wrap noted. Left heel/foot was resting on the metal foot pedal. No offloading boot was noted. R6 was asked if she ever wore a big boot on her left foot or does staff apply boot and R6 stated, no.On 2/5/2026 at 3:45PM discussed with V2 the Facility Wound Summary. Discussed the summary had information of R6's wound to her left buttocks but does not show a recent measurement of the wound and the last measurement was on 12/26/2026. V2 stated well maybe it is healed. V2 was asked why there were still orders for treatment to the left buttocks on the Physician Order Sheet with a start date of 1/2/2026. On 2/5/2026 at 3:50PM R6 was taken to her bathroom with V13, and a CNA present and an assessment was done and there are no open areas to the left buttocks. V13 validated there were no open areas to R6's buttocks.On 2/5/2026 at 3:55PM, V2 was informed there were no open areas to R6's buttocks. V2 was asked why there would still be an active order for the treatment and V2 stated I am working with new young nurses, and they have a lot to learn. V2 was asked if he expects the nurse to follow physician orders and V2 stated yes. V2 was asked if he expects the staff to apply offloading boots on the residents with orders for the boots and V2 stated of course I do. On 2/10/2026 at 8:36AM, V22 Nurse Practitioner (NP/Wound clinic) returned call and stated she does see R6 in the clinic for wound care to the left heel. V22 stated R6 has never seen her off loading boot to her left heel and when she asks R6 why she doesn't have it on, R6 stated the staff says I don't need it anymore, so they do not put it on. V22 was asked if she felt like the off-loading boot is needed, V22 stated yes, it would help with the healing off the wound and the boots also help prevent wound from occurring for residents at risk. V22 stated the wound to the left heel is improving but if she had the boot on as ordered it would probably improve faster. V22 stated she sees R6 in the clinic every 2 weeks. R6 's Progress Note dated 1/16/2026 titled Weekly Skin Assessment documents R6 refused to move coccyx wound to be assessed I'm tired. Skin overall within normal limits for age and race. Buttocks: Unable to Assess. Left Heel dressing clean dry and intact. 1/30/2026 documents R6 refused weekly skin assessment. On 1/30/2026 notes R6 refused to participate in weekly skin checks, would not turn and reposition, only limited exam was able to complete.On 2/10/2026 at 9:10AM when V12 LPN was asked about offloading boots/orders for R1, R2, and R6. V12 stated R2 will not wear the boots because she states they make her feet hot, R1 usually request the boots to be on especially while in bed, and R6 is hit and miss when she will allow the boots to be put in place. V12 was asked if she knows why R2 only has 1 boot in her closet and has an order for boots to bilateral extremities and V12 stated, I don't know. V12 stated she has placed boots on R1 several times, she has offered R2 boots a few times, and R6 sometimes won't allow you to put the boot on. V12 asked this surveyor if the boots were ordered on these residents for while in bed only and V12 explained how the order read which was twice a day 6:00AM-6:00PM and 6:00PM-6:00AM. The facility policy titled Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol revised 10/16/2024 documents objectives and purpose: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury or pressure ulcer that might develop. Principles: 3. All high and moderate risk residents will be assessed for the needs of the items and include Elbow/heel protectors/ bridging of heels.

Based on observation, interview, and record review the facility failed to implement standard precautions when providing resident care for 1 of 3 residents (R2) reviewed for infection control in a sample of 6.The findings include:R2's Face Sheet documents admission date of 5/12/2022 with diagnoses including Chronic Atrial Fibrillation, Osteoarthritis, Anemia, Essential Hypertension, History of Transient Ischemic Attack (TIA), and Sleep Apnea.R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 indicating R2's cognition is intact. The same MDS documents R2 is dependent on staff for sit to stand, chair/bed-chair, and toilet transfer; R2 is dependent for toileting; and R2 requires substantial/maximal assistance with lying to sitting on side of bed and sitting to lying. Section H, Bladder and Bowel, documents R2 is occasionally incontinent of bladder and bowel.R2's Care Plan documents a focus of Resident Care Information dated 5/12/2022, R2 is incontinent of bladder and bowel and R2 has a personal history of urinary tract infections, with interventions of assist R2 with peri care/incontinence care as needed.On 2/5/2026 at 6:17AM, V9 (Certified Nurse Assistant/CNA) was observed providing peri care to R2. R2 was positioned on left side. V9 removed R2's incontinent brief and began cleaning R2's right buttocks with disposable wipes. After V9 used the disposable wipe to clean R2, V9 threw the wipe in the floor. R2's brief and bed pad were soaked with urine and had a strong urine odor noted. V9 stated he needed to go get a clean pad. V9 left the room, without doffing his gloves or performing hand hygiene, and used his gloved hand to open the door. V9 was then observed getting a clean pad from the clean linen cart and returned to R2's room wearing the same gloves. When V9 returned to R2's room, he then then doffed his gloves and put on a new pair of gloves without performing hand hygiene between glove changes. V9 placed the clean bed pad under the linen and a new disposable brief on R2's bed. When V9 was finished getting linens positioned, V9 stated he would need help and left the room again, without doffing his gloves or performing hand hygiene. V9 returned to the room, wearing gloves, with V4 (CNA) to assist. R2 was then tuned to her right side and V9 continued to clean the left buttocks and removed the dirty brief and pad. When V9 removed the soiled bed pad, disposable wipes, and soiled brief from R2's bed, V9 threw them on the floor. When the disposable brief was thrown into the floor, urine was observed splashing onto the floor. V9 then repositioned R2 on her back and began washing R2's peri area. After each wipe, V9 continued to throw the used disposable wipes on the floor. Once peri care was completed and R2 was repositioned, V9 started gathering soiled items off the floor. V9 bundled the used disposable wipes and soiled brief together and folded the soiled bed pad placing it under his arm with the pad touching the right side of his uniform. V9 was observed leaving the room, without doffing his gloves or performing hand hygiene, and went and placed items in the trash and the soiled linen barrel, removing lids with the same gloves still on. V9 then went to the end of the hall, doffed his gloves, and washed his hands.On 2/5/2026 at 6:27AM, V4 CNA was asked if it is policy to place soiled wipes, briefs, and pads on the floor. V4 stated that you must put those items in a bag. V4 was asked if gloves should be worn in the hall and getting items out of the clean linen cart with the same gloves that one used during peri care, V4 stated, no you have to take off the gloves and perform hand hygiene.On 2/5/2026 at 6:30AM, V2 Director of Nursing (DON) approached this surveyor outside of R2's room and asked how the care went. This surveyor informed V2 of the infection control concerns observed with R2's care. V2 was asked if disposing of wipes and soiled brief on the floor during peri care were acceptable practices and V2 stated no.The facility policy titled Infection Control with revision date of 12/17/2019 documents Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions should be applied to the care of all residents regardless of the suspected or confirmed presence of an infectious agent. Standard precautions include but are not limited to 1. Hand Hygiene.3. Proper use of PPE (Personal Protective Equipment), gloves, gowns, mask, etc.5. Care of the environment, textiles, and laundry, 6. Handling of equipment, 7. Disposal of waste. The facility will handle all linen as potentially contaminated using standard precautions.

Based on observation, interviews, and record review the facility failed to ensure a call light was within reach for 1 of 3 residents (R2) reviewed for accommodation of needs in a sample of 6. Findings include:R2's document titled Face Sheet documents admission date of 5/12/2022 and includes Chronic Atrial Fibrillation, Osteoarthritis, Anemia, Essential Hypertension, History of Transient Ischemic Attack (TIA), and Sleep Apnea. R2's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 15 suggesting R2's cognition is intact. R2's MDS documents R2 is dependent on staff for, sit to stand, chair/bed-chair transfer, and toilet transfer and that R2 requires substantial/maximal assistance with lying to sitting on side of bed and sitting to lying. R2's Care Plan documents R2 is at risk for falls. Interventions are to instruct residents to call for assistance before getting out of bed or transferring. Orientate residents to room, surrounding areas, and use of call light system. On 2/4/2026 at 11:05AM, R2 was observed sitting in the back of her room in her wheelchair. R2 did not have call light within reach. R2's call light was noted to be tied to left side of bed on the handrail. R2 was noted to be several feet from call light. On 2/4/2025 at 12:27PM, R2 was observed sitting in the same spot in her room and did not have a call light within reach. On 2/4/2026 at 12:55PM, V3 Certified Nurse Assistant (CNA) was asked if she cared for R2 and V3 stated yes. V3 showed where R2 was sitting in her room and V3 stated she sits there most of the time. V3 was asked why she sat so far away from the call light, V3 stated well she pushes herself back there. V3 was not sure if R2 could move up closer to the call light but knows she can push herself back. On 2/4/2026 at 1:10PM V4 (CNA) stated R2 does sit in that spot and the call light will not reach over there but R2 pushes herself backward out of reach of the call light.On 2/4/2026 at 2:10PM, V2 Director of Nursing (DON) stated R2 does sit in that spot in her room but wasn't sure if the call light would reach because they do have long cords on the call lights. V2 stated, I do know that R2 pushes herself there. V2 was asked if this was a concern with R2 not having access to the call light for long periods of time and V2 stated he would check out the situation and must make adjustments. On 2/5/2026 at 12:25PM, R2 was noted to be sitting up in wheelchair eating lunch. R2 was sitting again in the back of the room and call light was 8.5 feet away from R2. Call light was tied to the left side rail which is the side rail farthest away from R2. Call light was untied and stretched as far as it would go towards R2 and measured 8.5 feet away from R2. R2 was asked if she pushed herself in her wheelchair to the back of the room, R2 stated yes I can push myself back. R2 was asked why she chose to sit to the back of the room where she is without reach of her call light. R2 was asked if she could move herself back up to use her call light and R2 stated well that is where I have trouble, the shoes I wear are slick on the floor and I can't hardly go forward. R2 stated if I need help, I will try to get up to the call light and hope that I can. R2 stated sometimes I call my daughter or try to make my way to the doorway and start yelling at the staff for help. On 2/6/2026 at 11:31AM, V15 (R2's Daughter) was asked if she had seen R2 sitting in the back of her room and V15 stated yes most of the time. V15 stated she visits weekly. V15 stated R2 likes to sit by the window. V15 was asked if R2 was able to propel herself forward in the wheelchair and V15 stated that is a struggle for R2, and she takes a long time to get very far. V15 was asked if R2 ever calls her if she needs anything when she can't reach her call light, V15 stated yes she does quiet often. V15 stated she didn't realize the call light would not reach back there to where R2 sits and stated that it is concerning her and is a risk for several things to happen. Policy titled Resident Rights dated revision date of 11/28/2017 contains documentation of F558-Reasonable Accommodation of Needs/Preferences: the right to reside and receive services in the facility with reasonable accommodation of residents' needs and preference except when to do so would endanger the health or safety of the resident or other residents.

Based on interview and record review, the facility failed to complete timely quarterly Minimum Data Set (MDS) assessments for 2 (R27 and R76) of 19 residents reviewed for quarterly MDS assessments in a sample of 37. The Findings Include: 1. R27's Resident Face Sheet documented an admission date of 10/4/22. The same document does not document when the last qualifying hospital stay was. R27's most recent completed quarterly MDS is documented as being completed on 5/3/25. An MDS 3.0 NH (Nursing Home) Final Validation Report with a submission and print date of 6/27/25 documented a Target Date of 5/3/25 for R27's MDS submission. This same report included a warning message that documented Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). 2. R76's Resident Face Sheet documented an admission date of 1/29/24. This same document does not document when the last qualifying hospital stay was. R76's most recent completed quarterly MDS is documented as being completed on 5/1/25. An MDS 3.0 NH (Nursing Home) Final Validation Report with a submission and print date of 6/27/25 documented a Target Date of 5/1/25 for R76's MDS submission. This same report included a warning message that documented Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). On 6/27/25 at 11:00 AM, V1 (Director of Nursing/DON) confirmed that these warning messages confirm that the quarterly assessments transmitted were considered to be past due/late. The facility policy with the subject of MDS Completion, revised 4/1/25, documented it is the policy to provide a system to complete standardized assessments in a timely manner, according to the current Resident Assessment Instrument Manual. Under Compliance Guidelines #9. Medicare PPS (Pay Per Service) assessments, scheduled and unscheduled, will be completed within 14 days of the assessment reference date. The type of assessment reference date will adhere to Medicare guidelines for each assessment. Under Transmission and Validation, documents 1. PPS and Quarterly Assessments will be transmitted within 14 days of the completion date in Z0500B. Reference Chapter 5, Section 5.2 3. The MDS Coordinator will obtain validation report, review error messages, and correct any substantiated errors. If an error is identified, the MDS Coordinator will modify or inactivate per the RAI manual guidelines and transmit. 4. The MDS Coordinator will transmit a minimum of weekly to ensure timely validation of MDS acceptance.

Based on observation, interview, and record review, the facility failed to maintain aseptic technique while providing wound care for 1 (R88) of 1 resident reviewed for infection control in a sample of 37. Findings included: R88's Resident Face Sheet documented an admission date of 4/15/2025 and included diagnoses of prediabetes, bacterial infection, unspecified-RLE (right lower extremity), and non-pressure chronic ulcer of right calf with unspecified severity. R88's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, indicating R88 has severe cognitive impairment. Under section M, Skin Conditions, C.1, documented one stage 3 pressure ulcer. R88's Physician Order Sheet (POS) dated 5/20/2025 documented an order for clindamycin 100 mg (milligrams)/mupirocin 20 mg/gentamicin 80 mg. Empty 2 capsules into mixing container to reconstitute with 2 vials of NaCl (Sodium Chloride) 0.9% solution: transfer to spray bottle and apply to wound on Right LLE (Lower Leg Extremity) PRN (as needed) for soiled/excessive draining cover with ABD (abdominal) Pad, roll with kerlix, secure with tape and tubi grip PRN. On 06/25/25 at 1:56 PM, V2 (Licensed Practical Nurse/LPN) provided wound care to R88's right lower leg extremity. No barrier was placed under R88's right calf during wound treatment. V2 removed the old elastic tubi grip with scant amount of drainage noted. V2 placed the dirty tubi grip on the clean field with supplies. V2 then removed the dressing with moderate amount of drainage noted. V2 wrapped the dirty dressing up in her gloves while removing them and placed the dirty gloves with the dressing on her clean field with supplies. On 06/25/25 at 2:03 PM, V2 (LPN) stated, she should have placed a barrier under R88's right lower leg extremity prior to starting her wound treatment. V2 also stated she should not have put dirty elastic tubi grip, the dirty gloves or dirty dressings on her clean field. V2 stated the dirty items should have gone in a trash bag. On 06/25/25 at 2:57 PM, V1 (Director of Nursing/DON) stated, his expectations are for all staff to follow standard infection control precautions and he would not contaminate a clean field with dirty items. The facility policy for Wound Dressing Change (Clean) (undated) documents under Objective .To protect wound and promote healing, to prevent irritation, and to prevent infection and spread of infection. Documented under Procedure .prepare bag for discarding waste, use towel to establish clean field .remove soiled dressing and discard in biohazard bag.

Based on interview and record review, the facility failed to maintain a shower chair in a safe condition for 1 (R1) of 6 residents reviewed for accidents in the sample of 6. This failure resulted in R1's foot getting caught in the rubber strips of the shower chair causing a nondisplaced spiral fracture of shaft of right tibia. This past non-compliance occurred between 1/24/25 and 1/28/25. R1's face sheet documents R1 was admitted to the facility on [DATE]. The same face sheet list some of R1's diagnoses as nondisplaced spiral fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, Unspecified dementia, unspecified severity, with other behavioral disturbance, squamous cell carcinoma of skin of unspecified upper limb, including shoulder. R1's MDS (Minimum Data Set) dated 1/3/25 documents R1 has a BIMS (Brief Interview of Mental Status) of 99, which indicates R1 was unable to complete the interview. The same MDS notes R1 has impairments of both upper and lower extremities, is dependent for showering/bathing self and tub/shower transfer. R1's Serious Injury Incident and Communicable Disease Report dated 1/25/25 documents R1 had an injury of known source that happened on 1/24/25. This report documents V8 (CNA/Certified Nurse Assistant) and V13 (CNA) were pushing R1 in a shower chair to the shower room when R1 screamed out my leg, my leg. When V8 looked down R1 foot had slipped through the slats of the footrest and was stuck. When getting the foot free, V8 heard a pop in R1's ankle. R1 was send to the ER (emergency room ) and was admitted for a right tibia fracture. The report documents the shower chair was removed from service and education was done for all staff on safe transfers and ambulation of residents. On 2/18/25 at 8:45 am, V1 (Administrator) said she is familiar with the incident of 1/24/25 with R1. V1 said she did do an investigation, just not a full investigation since the problem was clear. V1 said she did take statements from the involved staff and if they didn't know what happened, she would have investigated it further. V1 stated she also had them do a return demonstration of what happened. V1 said that the shower chair in question was taken out of use until maintenance looked at it. V1 said that the plastic strips were stretched out and loose on the leg area of the chair. On 2/18/25 at 1:40pm, V8 (CNA/Certified Nurse Assistant) said that her and V13 (CNA) were getting ready to shower R1. V8 said that they were in R1's room and had placed her in the shower chair using a mechanical lift. V8 said the left pad was left underneath R1. V8 said they opened R1's door and began pushing her to the shower room. V8 said that on the way, R1 yelled my leg, my leg. V8 said she stopped pushing the chair immediately. V8 said this is when she saw that R1's foot had went through the rubber strips in the chair. V8 said they went on and pushed her in the shower room for privacy and when they got to the shower room, she pushed the lever to lower the foot rest down and that didn't help to get her foot out. V8 said she held R1's knee with one hand and the foot with the other and this is when she heard a pop. V8 said that R1's foot was turned out after the pop and she sent V13 to get the nurse. V8 said that the nurse came in and called V3 over to look at it also. V8 said that V3 bandaged the skin tear on R1's leg. V3 said that R1's leg was starting to swell a little. V8 said that the nurse said they were sending her to the emergency room for evaluation. V8 said they cleaned R1 up and got her dressed and put R1 back in bed while waiting on the ambulance to come. On 2/18/25 at 2:10pm, V13 (CNA) said she was working with V8 when the incident with R1 occurred. V13 said that her and V8 had transferred R1 from her bed to the shower chair using a mechanical lift. V13 said when they were pushing R1 to the shower room, R1 said my foot, my foot. V13 said they stopped and looked and then noticed R1's foot was caught in the rubber strips on the shower chair. V13 said that V8 was trying to get R1's foot out, and felt and heard a pop. V13 said she immediately went to get the nurse. V13 said that V3 bandaged the skin tear that was bleeding. V13 said they got R1 cleaned up and dressed and put her back in bed to wait on the ambulance. On 2/18/25 at 10:30 am, V3 (RN/Registered Nurse) said she was on duty the evening of 1/24/25. V3 said the nurse on R1's hall was new, and she called V3 to come over and help her. V3 said when she got there, the CNA's (V8 and V13) told her they heard a pop when they were getting her foot out of the rubber strips. V3 said the mechanical lift pad was underneath R1 and she was sitting like normal in the shower chair. V3 said that R1's right shin was bleeding from a skin tear and she cleaned the wound and applied steri strips. V3 said she agreed with the nurse on that hall that R1 needed to be sent out for evaluation. V3 said she was not aware of any problems with the shower chairs prior to the incident. V3 said the chair was taken out of use until maintenance could look at it. On 2/18/25 at 9:20 am, V2 (DON/Director of Nurses) said the incident with R1 was reported after it happened on 1/24/25 by one of the nurses. V2 said that V8 (CNA/Certified Nurse Assistant) and V13 (CNA) were taking R1 to the shower by pushing her in the shower chair from R1's room. R1 said the shower chair has a foldable layout with rubber strips. V2 said that R1 yelled my foot, my foot. V2 said staff looked and found that R1's foot had went through the rubber strips. V2 said he did an in-service later that evening on proper transfers. V2 said the chair was taken out of use until maintenance could look at it. V2 said the corporate guy (V5/Regional Therapy Consultant) and V4 (Maintenance Director) both looked at the chair and said the rubber strips were a little loose. V2 said that the nurses on duty that night were V3 (RN/Registered Nurse) and the other nurse was on vacation at this time. On 2/18/25 at 10:40 am, V4 (Maintenance Director) said the chairs have rubber strips on them and they do get stretched out with use. V4 said he did inspect the shower chair the next day and the rubber strips were loose and stretched out. V4 said he tightened them up. V4 said that he checks the kitchen equipment monthly, but does not check shower or bathroom equipment except on an as needed basis. V4 said he is now doing daily checks of bathroom/shower equipment. On 2/18/25 at 10:50 am, V5 (Regional Therapy Consultant) said he looked at the shower chair with V4. V5 said one of the strips was loose and it was fixed immediately. V5 said that they do monthly checks on equipment like mechanical lifts, sit to stands but that bathroom equipment like shower chairs is done on an as needed basis. R1's Resident Progress note dated 1/24/25 at 4:05 pm documents, CNA alerted this nurse that during a transfer to the shower chair her right foot got tangled up and they heard a snap/pop and the patient yelled in pain also received a skin tear to the front of her shin, measures 4.5 cm (centimeters) x 4 cm, well approximated with 6 steri strips and optifoam on top for bleeding. This nurse assessed the foot/ankle and noticed swelling and that the skin is hot to the touch. The patient also yelled when this nurse tried to move her foot to look at it resident is being sent to ED (Emergency Department) for eval. Local Hospital Document labeled Hospital Discharge Summary notes R1's admitted [DATE] and discharge date of [DATE]. The same document notes R1's initial encounter presented from Nursing Home for Right ankle pop .X-ray of Right ankle reveals open distal tibial fracture per my read ortho has been consulted, plans to see in the am, patient had right ankle splinted, now being admitted for further evaluation. The same document notes an X-ray done on 1/25/24 with an impression of mildly displaced oblique fracture of the distal right tibia. Facility Document labeled Policy, revised on 11/12 note Our safe Resident Handling Program is designed to meet the following Goals Protect staff and Residents from injury. The same document also noted under Procedure .#7. To ensure equipment is in proper operating condition, maintenance personnel will be designated to make regular equipment checks. Prior to the survey date, the facility took the following corrective actions to correct the non-compliance: On 2/18/25, V1 provided a form labeled Department Head meeting dated 1/28/25. V1 said that the incident with R1 was discussed at their morning meeting on 1/28/25. V1 said they discussed all of the residents it effected, and preventing accidents in the future. V1 said their next QAPI meeting is the end of February, and this topic will be discussed again then. On 2/19/25 at 1:20pm, V1 said that all department heads attend morning meeting and they are also members of the QAPI (Quality Assurance and Performance Improvement) committee. On 2/18/25 at 2:30pm, V1 said that the DON did an in-service on 1/24/25 on proper transfers. 1. Immediate Corrective Action: Staff were in-serviced on 1/24/25 on Safe Resident Handling. 2. System Maintenance: Plan of Correction Audit Tracking note that equipment (shower chair) are being checked for safety at least weekly. 3. Other Residents with the Potential to be Affected: All residents have the potential to be affected by the alleged deficient practice

Based on interview and record review the facility failed to administer pain medication as ordered and develop interventions to manage pain for 1 of 5 residents (R2) reviewed for medication administration in the sample of 7. This failure resulted in R2 experiencing increased pain due to missing 4 doses of ordered pain medication on 8/10/24, 8/11/24, and 8/12/24. The findings include: R2's Face sheet documents an admitted [DATE] and includes diagnoses of encephalopathy, end stage renal disease, weakness, low back pain, malignant neoplasm of left kidney except renal pelvis, weakness and hemodialysis. R2's Minimum Data Set (MDS) dated [DATE], section C, Cognitive Patterns, documents a Brief Interview for Metal Status (BIMS) score of 15 indicating R2 is cognitively intact. Section GG, Functional Abilities and Goals, documents R2 requires substantial/maximal assistance with toileting hygiene and shower/bathing, lower body dressing and putting on and taking off footwear, and partial/moderate assist with upper body dressing. Section J, Health Conditions, documents under Pain Management, within the last 5 days (of assessment 7/26/2024) Received scheduled pain medication regimen? with a documented answer of no. The same section documents the questions within the last 5 days, received PRN (as needed) pain medication or was offered and declined? and received non-medication intervention for pain? with documented answers of yes. Under the section titled Pain Assessment Interview of section J of the same MDS dated [DATE], documents the answer of No to the question of have you had pain or hurting at any time in the last 5 days? R2's Care Plan dated 7/25/2024 does not contain problem or focus area regarding pain and does not include any interventions or approaches to manage R2's pain. R2's Pain Management Observation completed on admitted d 6/24/24, documents the answer yes to the question Have you had pain or hurting at any time in the last 5 days? and documents the pain site of back pain. The onset of pain is documented as mid morning and afternoon, duration of pain as comes and goes, and other expressions of pain as crying/whining, grimacing/clenched teeth, and bracing/guarding/ rubbing affected area. On 8/13/2024 at 2:38 PM, R2 is an alert and oriented male resident observed lying in bed in the fetal position. R2 stated I am in bad pain R2 explained he had a fall the other day when he tried to get up and open his door, he stated he took one step and fell . R2 stated I have bruises to my right butt. R2 stated I am asking for pain medicine now; I usually get my pain medicine, but I had to wait last night, and I was hurting bad. R2 stated he usually gets it around 7 PM but last night (8/12/24) he had to wait until 10 PM because the nurse went on break before she gave him his pain medicine and he was hurting bad for 3 hours. R2 stated they are very particular about pain medications, I ask for it and it takes a long time, I have been asking for a while right now, my back is hurting bad. While in the room with R2, V9 (Licensed Practical Nurse/LPN) came in with pain medication stated to be Hydrocodone-acetaminophen 5/325mg. R2 was given Hydrocodone-acetaminophen 5/325mg by mouth. V9 stated I am trying to get R2's pain under control as R2 is having bad back pain that has increased since the fall. V9 stated R2 is getting Tylenol in between pain meds to help with breakthrough pain. R2 stated The Tylenol is not helping me very much. V9 stated R2's pain medication is now every 6 hours and the next dose will be due at 8:00 PM. V9 offered R2 a warm compress to R2's back to help with the pain and R2 accepted and stated, I will try anything because this pain is bad. V9 stated R2's pain medication is scheduled at 8AM, 2 PM, 8 PM and 2 AM. R2 stated it takes about an hour for the pain medication to start easing the pain. V9 asked R2 to rate his pain and R2 responded it is a 8-9 on a 10 point pain scale. V9 stated she had given Tylenol around 10 AM and R2 stated that didn't help anything. R2's Physician's Order Report dated 6/24/2024 -8/15/2024 documents the following orders: Hydrocodone-acetaminophen 5/325 mg (milligrams) every 6 hours as needed dated 6/24/2024 and a discontinuation date of 7/25/2024, hydrocodone- acetaminophen 5/325mg twice daily dated 7/25/24 and a discontinuation date of 7/30/2024, hydrocodone- acetaminophen 5/325mg three times a day dated 7/30/24 and a discontinuation date of 8/12/2024, hydrocodone- acetaminophen 5/325mg every 6 hours dated 8/12/24 and a discontinuation date of 8/13/2024, and a current order of hydrocodone- acetaminophen 5/325mg dated 8/13/2024 every 4 hours. All hydrocodone- acetaminophen 5/325mg orders have a documented diagnosis of low back pain. The same Physician's Order Report documents a current order dated 6/24/24 for Lidocaine adhesive 5% patch, 1 patch topical once a day for low back pain and an order dated 6/25/24 for acetaminophen 325 mg 2 tablets every 6 hours as needed for low back pain. R2's Medication Administration Record (MAR) with a date range of 8/1/24 through 8/20/24, documents that Hydrocodone-acetaminophen 5-325 MG tablet was Not Administered: Drug/Item unavailable on the following dates and administration times: 8/10/24 at 5:00 PM, 8/11/24 at 5:00 PM, 8/12/24 at 7:00 AM, and 8/12/24 at 2:00 PM. The same MAR documents an order of Assess pain Q (every) shift using the 0-10 pain scale or verbal descriptor scale. R2's pain is documented as a 6 on shift 2 (6PM to 6AM) on 8/10/24, as 9/10 on shift 1 (6AM to 6PM) on 5 on shift 2 on 8/11/24, as 8/10 on shift 1 and 7/10 on shift 2 on 8/12/24. R 2's Progress Note dated 8/12/2024 at 6:03 AM, documents resident gets hydrocodone5-325mg three times a day with PRN (as needed) Tylenol (acetaminophen) throughout the night as needed. Resident is still very much in pain and states that it is generalized, and the pain pills are not controlling his pain and moans in pain. NP (Nurse Practitioner) on call and notified for further orders. R2's Progress Notes dated 8/12/2024 at 11:53 AM by V2 documents, (V14 Nurse Practitioner) gives updated order to increase Norco (Hydrocodone-acetaminophen) to QID (4 times a day/every 6 hours). One time order for Tramadol 50 mg now related to pain prior to appointment. On 8/13/2024 at 4:00 PM, V2 (Director of Nursing) stated I know R2 ran out of pain medications on Sunday 8/11/2024 and just gave him Tylenol for his back pain. V2 stated R2 has chronic back pain and hurts most of the time. V2 stated R2 was on pain medications 3 times a day and V2 got orders to increase the frequency to 4 times a day which is every 6 hours to help with the increased pain since the fall. On 8/202/2024 at 8:33 PM, V28 (Licensed Practical Nurse) was asked if she had to get medications out of the Stat Safe Machine (emergency medication kit) for R2, she stated she has had to get his pain medications out of there but there was a time recently when there were no more Hydrocodone-acetaminophen 5-325 mg in the Stat Safe Machine so there were none available to administer to R2. V28 stated R2 had bad back pain and as of recently the pain medications kept getting increased to help control the pain as the pain was bad. On 8/20/24 at 10:14 AM, V14 (Nurse Practitioner) said she was called about increase pain so she increased R2's pain medications. V14 was asked if she was aware R2 went without pain medications at times and she stated I know they do run out of medications but they know they should always notify me or the on call (physician) because we will always give orders for available medications from the emergency kit, even though it may not be exactly what was ordered originally but we can substitute until the original medications is delivered. V14 stated Nobody should go without medications, there is a ton of options in the emergency kits. V14 stated she had met with R2's family member in late July and they discussed how R2's pain was getting worse and they had even discussed palliative care in the future. V14 stated R2's family member is very realistic and stated (R2) is miserable with his pain. V14 stated R2 was also kind of hit and miss with his dialysis as well and some of it has to do with his pain. V14 stated R2 didn't always want to participate in therapy or get up. V14 aid R2 wanted to stay on his side with his knees bent up for comfort. That was his position that helped with the pain. V14 stated that it is very sad because R2 was such a kind man and he was very alert and oriented. The facility policy titled Pain Management Policy with revision date of 3/3/2022 documents The facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy. Purpose: To identify residents experiencing pain to establish control of pain to the resident's satisfaction and to relieve related symptoms . Procedures: 5. An individualized care plan will be developed and implemented.

Based on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 1 of 3 residents (R1) reviewed for dignity in a sample of 7. This failure resulted in R1 having feelings of desertion, fear, frustration and embarrassment. Findings include: 1. R1's face sheet documents an admitted [DATE]. Diagnoses upon admission included Multiple Sclerosis, cellulites of left lower limb, edema, weakness, difficulty walking, foot drop of right foot, pain, depression, anxiety disorder. R1's MDS (Minimum Data Set) dated 6/14/2024 includes a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. Section GG Functional abilities and goals) indicates R1 requires substantial/maximal assistance with toileting, hygiene, also indicates R1 is dependent for walking, sit to stand, chair to bed and toilet transfers. R1's Care plan dated 6/20/2024 indicates, problem of resident at risk for falling related to recent illness/hospitalization and new environment with approach dated 6/1/2024 to instruct resident to use call for assist before getting out of bed or transferring. Encourage resident to stand slowly. Problem start date of 6/1/2024 section named Resident Care Information with approach dated 6/1/2024 indicates bowel and bladder: incontinent, incontinent products, small pull ups. On 8/13/2024 at 3:45 PM, R1 was observed sitting outside on the front porch of the facility visiting with a friend. R1 was alert and oriented. R1 was sitting in wheelchair which she was able to propel around in independently. R1 stated, I did live alone just a few months ago but I had a fall transferring myself, so I landed in the hospital and then was transferred here for therapy. R1 stated, My hopes are to get my strength back and go back home. R1 stated, My diagnosis is a tough one to stay ahead of but with my determination I believe I can stay at home a few more years and stay self-sufficient which isn't the normal for most people, but I have learned to adjust. She said she doesn't want to get anyone in trouble, and she knows how short staffed they are around here, but the care is just not very good. R1 stated the weekends are the worst but last Sunday was horrible. R1 stated she was on her call light asking for help for hours but there was nobody to help her. R1 stated the Occupational therapist was there and she is the one who finally came and helped me get cleaned up and was soaked in urine. My family came and took me home for the day. On 8/14/2024 at 9:14 AM, R1 was asked to explain what occurred on Sunday 8/11/2024. R1 stated, I was on my call light for hours needing assistance as I needed to use the bathroom. R1 stated she does have episodes of incontinence but for the most part she is able to feel the urge and get to the bathroom with assistance in time. R1 stated, I am really OCD (obsessive compulsive disorder) about continence. I use liners and I do not like being wet so I try to ask for assistance at the first feeling of urgency so I can stay dry. R1 stated, 'Sunday felt like the longest day of my life. There was nobody here to help us and I felt deserted. R1 stated she could hear all the lights ringing nonstop but there was just no help. R1 stated, I was totally soaked through my clothes, and I had to lay like that for hours. R1 stated, I started asking for help before 6 AM and it was after 10 AM before anyone was able to help me. The one that helped me was the OT (Occupational Therapist). R1 was asked how this made her feel and she stated, I was crying so much, I felt deserted, and I was frustrated, embarrassed, and fearful. R1 stated, I fear this will happen again and I know it will because they do not have enough staff to take care of us especially on the weekend. I know it is not their fault and some of the staff go above and beyond but they can't work every day of the week, and they can't do it all either. I was supposed to go to my daughter's house, and I did get to go but we were 2 hours behind leaving because I wasn't ready, nobody could help me get ready. On 8/14/2024 at 11:15 AM, V8 COTA (Certified Occupational Therapist Assistant) stated, I work Sunday through Thursday at the facility. V8 stated, I worked this past Sunday. V8 was asked if there was anything unusual about Sunday 8/11/2024, V8 stated the weekends are always bad, but this past Sunday was bad. V8 stated, I was trying to help by changing resident and getting them up, as I was seeing resident for their therapy. V8 was asked if she cared for R1 and V8 stated yes, I noticed in between my patients that I was treating that (R1's) call light had been on for a long, long time, approximately 45 minutes. She said she went into R1's room to check on her and when she entered the room the smell of urine was very strong as soon as she walked into the room. (R1) was lying in bed crying and was very upset. She said she felt bad for her as (R1) was so soaked with urine, it was so bad. V8 stated (R1) was so embarrassed and just kept apologizing to me for being in such bad shape, it was so sad. V8 stated (R1) is totally dependent with walking so she can't get up by herself. V8 stated, I just started getting her cleaned up. R1 was soaked through the pad, depends, night clothes, bed pad and sheet down to the mattress. the mattress was even wet. V8 stated R1 was even wet all the way up her entire back. V8 said (R1's) family member came in just as she was finishing, and the family member said R1 had been texting her since early that AM stating she needed help. On 8/14/2024 at 2:10 PM, via phone interview, V26, R1's family member stated on Sunday 8/11/2024, R1 called her crying that morning and so she went out to the facility. V26 stated R1 was in a very depressed state. V26 stated she got there just as they were cleaning her up and staff had to change everything as she was soaked in urine. V26 stated weekends are low staff, the ones that show up are good but there are too many residents for just a few staff to care for. V26 stated, Something needs to be done because (R1) was distraught on Sunday and not in a good place when I got here on Sunday. None of the residents deserve this kind of care. On 8/15/2024 at 2:50 PM, V21 (Certified Nurse Assistant/CNA) stated she takes care of R1 frequently. V21 stated R1 is continent of bowel and bladder. V21 stated R1 lets the staff know when she has the urge to use the bathroom and they take her to the bathroom. V21 states R1 still wears a depends (adult brief) because she is always afraid, she may have an accident and that would embarrass R1 as she is very conscious of her hygiene. On 8/14/2024 a call light log provided by V2 was reviewed. The document contained room numbers, time the call light was started and the time the call light was ended. The call light log recorded R1's room for 8/11/2024 as start time 8:24:49 am and end time 9:26 :31am with duration of 1:01:42. On 8/13/2024 at 4:00 PM, V2 was asked if he was aware of call lights not being answered in a timely manner and residents had long wait times for care, V2 stated he was not aware of any real issues. V2 was presented with the document (unnamed) that V2 provided, a log with room numbers, when call lights were triggered with hour, minutes, and seconds, (start time) and call light end time and dates. A specific date was presented to V2 of 8/11/2024 for R1's call light, start time was 8:24:49 am and end time was 9:26 :31am with duration of 1:01:42. V2 was asked to interpret the duration time and V2 stated that is 1 hour, 1 minute and 42 seconds and I missed seeing that when I gave you the call light usage report. V2 was asked if this was acceptable practice and V2 stated, No not at all. V2 was asked what the expectation was for the duration time of call lights being activated, V2 stated, 15 minutes or less. V2 was asked if he knows why this was an issue on 8/11/2024, V2 stated, because of staffing, it was bad. V2 was asked if care was provided adequately to the residents on 8/11/2024 during the day shift, V2 stated, evidently not. V2 was asked if the grievances pertaining to the past weekend were reviewed and V2 stated 'yes they were. On 8/14/2024 at 1:25 PM V19 CNA (Certified Nurse Aid/CNA Supervisor) stated she worked on 8/11/2024. V19 stated the weekends are always bad due to younger staff and they call in all the time or don't show up. V19 stated it is a real struggle but this past Sunday 8/11/2024 was the worse she has ever seen it. V19 stated it has been bad for last 6 months on the weekends. V19 stated trying to get staff. V19 said breakfast was late as well V19 stated R1 is normally continent of bowel and bladder and was made aware that V8 was able to get to her and get her cleaned up. V19 stated this is not acceptable care at all, the care was not good due to staffing. V19 stated I did the best I could but with only me it wasn't enough. Call lights were on too long. On 8/14/2024 at 8:45AM, V6 (Licensed Practical Nurse/LPN) stated he worked on 8/11/2024 and he stated they were very short on CNA's. V6 said it wasn't the idea situation, but we tried our best to take care of the residents. V6 stated he worked on 200 halls and was able to help change some residents and answer lights sometimes. On 8/15/2024 at 7:40 PM, V17 (LPN) was asked if she worked on 8/11/2024 dayshift, V17 stated, Yes and we only had 4 CNAs and there was only 1 CNA on the hall I was working on which was 100 hall. V17 said the care was really delayed that day. On 8/15/2024 at 8:45 AM, V13 (CNA) stated on Sunday 8/11/2024 the staffing was very short. V13 stated, The call lights were on longer than usual because normally we have 2-3 CNAs on that particular hall which is 300 hall, but Sunday there but she was the only one on the hall . V12 stated I wish it could have been better but I did the best I could do. V13 stated V15 CNA came in at around 11:30 AM and helped with lunch and left at 2:00 PM. The nurse on my hall could not help due to restrictions. On 8/14/2024 at 3:55 PM, V1 (Administrator) was asked if she was aware of there only being 4 CNAs in the facility on 8/11/2024. V1 stated, I received a text at 6AM but I didn't see it until I woke up at 7:45 AM and at that time I started calling people. V1 was asked if 4 CNAs for the 4 halls acceptable staffing numbers and she responded it is not preferred. V1 was asked if she was aware of the issues with care such as residents being left wet and call lights not being answered for long periods of time and she stated yes and had received grievances and had addressed the issues.

Based on observation, interview and record review, the facility failed to follow therapeutic dietary recommendations for residents at risk for weight loss for 1 of 1 (R64) resident reviewed for nutrition in a sample of 38. This failure resulted in R64 having a significant weight loss of 16.8% over a period of 6 months. The Findings Include: R64's Resident Face Sheet documents an admitted [DATE] and a date of birth of 7/18/42. This same document includes the following diagnoses: unspecified dementia, dysphagia, anxiety disorder, and cognitive communication deficit. R64's 06/2024 Physician Order Sheet documents a diet order for mechanical soft, high calorie/high protein (HCHP) diet. R64's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating that she is cognitively intact. This same MDS Section K0300 documents 'No' under the weight loss category question regarding Loss of 5% or more in the last month or 10% or more in the last 6 months. On 6/13/24 at 12:45 PM, R64's lunch tray was delivered to her room and had turkey, gravy, bread, mashed potatoes/gravy, vegetable medley, pineapple cake, and a red juice drink. R64's meal ticket included that R64 should receive a fortified whole milk-8 ounces, offer ice cream, offer egg salad, tuna salad and hard boiled eggs. R64 stated at this time she doesn't really like the food today and is not very hungry. R64 stated that sometimes she gets a pudding and/or milk but not every time and she is never offered the egg/tuna salad or hard boiled eggs. At this time, R64 had a pudding but not a fortified milk. On 6/13/24 at 1:00 PM, V21 (Certified Nurse Assistant/CNA) stated that the CNA's pass out the supplements that are prepared prior to the meal service, like pudding, milk or ice cream. Review of R64's Comprehensive Care Plan does not include a focus area for nutrition or weight loss. A 'Vitals Report dated 9/1/23-6/14/24 documents the following weights: September 2023-125.8 pounds, October 2023-125 pounds, January 2024-106 pounds, February 2024-100 pounds, March 2024- 104 pounds, and June 2024-96 pounds. R64's Resident Progress Note dated 3/27/24 by V10 (Registered Dietitian/RD) documents that RD wound/wt (weight) note. Weights (3/7) 104# (pounds), 2/27: 100#, 1/23 106#, 1/12 112, and 9/7 125.8#. Resident with 21% weight loss/6 months. Within normal limits of IBW (Ideal Body Weight) 108-138 pounds. Body Mass Index: 18 (underweight). Resident (underweight) with Stage 2 P.U. (pressure ulcer) Rt (right) upper buttock. On a mechanical soft diet (has signed a waiver for regular potato chips). High Calorie High Protein supplement. Intakes 25-27%. On Remeron which can increase appetite. Bilateral heels boggy. Plan: Continue Arginaid daily, MVI (Multivitamin), Vitamin C, and Zn (Zinc) for healing needs. To boost calories/protein. Re-Recommended. Add: Fortified Pudding at lunch and supper. Will monitor. Refer PRN (as needed). R64's Resident Progress Note dated 4/23/24 by V10 documents: Resident with resolved Stage 3 P.U., still has a Stage II P.U. on Rt buttock and P.U. on Lt (Left) buttock. Hx (history) poor-fair meal intakes. Remeron use may stimulate appetite. March 7 Wt 104 #, weights fluctuating. Continue M/S (Mechanical Soft) HCHP supplements all meals. Recommend fortified pudding at lunch and supper for additional protein. Monitor weights, intakes, skin. Refer PRN. On 6/12/24 at 2:00 PM, V2 (Dietary Supervisor) stated that for some reason the two dietary (computer) programs are not communicating. V2 determined that the orders are put in for the supplements, but the labels are not printing for the dietary staff to know to prepare these supplements. V2 further stated that the staff prepares the HCHP food items prior to each meal and delivers to the dining room the resident will be dining in. V2 stated that the staff are alerted to prepare these food supplements from labels generated (from the system). On 6/12/24 at 2:30 PM, V10 (Registered Dietitian) stated that anyone with a HCHP supplement ordered, it is procedure that residents will receive these supplements at all meals. V10 further stated that the only time that it would be specific to a certain meal would be when the order has that specific meal written in. When asked how V10 knows what residents require her assessment, V10 stated that she reviews charts offsite prior to her onsite facility visits twice a month to determine who needs to be evaluated. In addition, while onsite the staff can always let her know of any issues that need to be addressed that she was unaware of. On 6/12/24 at 3:00 PM, V9 (Physician) stated that when a resident has weight loss and/or is at risk and there are supplements ordered, he would then expect those supplements to be provided to prevent weight loss/increase the intake.

Based on observation, interview, and record review the facility failed to ensure effective interventions were implemented to prevent falls for residents with dementia were implemented for 4 of 7 (R9, R10, R69, R74) residents reviewed for falls in the sample of 47. This failure resulted in 1. R74 having a fall in the shower that resulted in a fracture of R74's tibia/fibula that required surgical repair, 2. R10 having a fall that resulted in a fractured clavicle and a right femoral neck fracture that required surgical repair, and 3. R69 having a fall that resulted in a fractured pubic ramus and a fractured humerus. Findings Include: 1. R74's Resident Face Sheet dated 4/29/22 documents R74 was admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)], weakness, nondisplaced oblique fracture of shaft of left fibula, restlessness and agitation, [CONDITION(S)], depressive episodes, and cognitive communication deficit and spinal stenosis. R74's MDS (Minimum Data Set) dated 3/14/22 documents R74 has a BIMS (Brief Interview for Mental Status) score of 02, which indicates R74 has severe cognitive impairment. The same MDS documents in Section G, R74 requires assist of one person for bed mobility, transfer, walking, dressing, toilet use, and personal hygeine and documents under Section J R74 has a history of falls. R74's [NAME] Hopkins Fall Risk Assessment Tool dated 1/17/2022 documents a score of 28 which indicates R74 is at high risk for falls. R74's Care plan dated 3/10/22 documents a problem area of R74 is at risk for falling R/T (related to) recent illness/hospitalization and new environment, [CONDITION(S)], (hypertension), cerebral infarction, AFIB, ([CONDITION(S)]), and incontinence. She has a low BIMS Score, sometimes a difficult time understanding/making others understand her. She has a history of crawling onto the floor at times. She does not comply with weight bearing recommendations d/t (due to) poor safety awareness and cognitive deficits. She (R74) is impulsive. The interventions for R74's fall problem area documented on 3/1/22 are as follows; redirect resident when observed in other resident room as tolerated, assist resident with activities of interest, encourage resident to use side rails/enablers as needed, instruct resident to call for assist before getting out of bed or transferring, encourage resident to stand slowly, orientate resident to room, surrounding areas, use of call light system, provide resident with specialized equipment: walker/wheelchair and therapy to evaluate and treat as ordered. Other interventions documented on R74's fall care plan are; 4/5/22-dump wheelchair, 3/21/22-encourage resident to sleep in her bed as tolerated, 3/14/22-assess footwear, 3/11/22-encourage resident to ask for assistance when carrying beverage as tolerated, 3/7/22-R74 loves pretty things. Offer pretty, sparkly bright, items throughout the day to sort through, and 3/7/22-encourage resident to lead order of tasks in shower as tolerated. On 4/26/22 at 10:44 AM, R74 was observed self-propelling wheelchair about the facility with an orthopedic type boot on her left foot/leg. R74's facility Event Report dated 3/2/22 documents under progress notes, 3/2/22 5:47 PM staff was attempting to assist resident with a shower resident became agitated and attempted to hit staff causing resident to fall to the floor resident did not hit her head. Resident complains of left ankle and left leg pain, bruising and swelling noted to areas, no other injuries noted. Resident refused pain med at this time, no other complaints of pain. V33 (Physician) informed, awaiting further orders .3/2/22 6:49 PM MD (physician) order xray of L (left) leg: (name of radiology company) contacted and will be out tonight. 3/2/22 8:02 PM .completed xray at this time. 3/2/22 9:46 PM Requested PRN (as needed) analgesic (pain medication) for c/o (complaints of) left ankle pain; only has routine Tylenol 650 mg TID (three times daily) and not due again until morning. V33 orders ibuprofen 400 mg TID PRN (as needed) x (times) 48 hours; notified of safety alerts. 3/2/22 10:16 PM Called to check on x-ray results . 3/2/22 10:52 PM Xray results received; Comminuted spiral fracture is seen of the distal tibia. Oblique nondisplaced proximal fibular fracture is seen. There does (sic) appear to be a subacute chronic transcervical right femoral neck fracture with a 8 mm (millimeter) displacement. V33 notified and orders to send to hospital 3/7/22 9:51 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/02. Intervention of encourage resident to lead order of tasks in shower as tolerated in place to prevent future occurrences. R74's local hospital report with a service date of 3/8/22 documents .patient (R74) w/hx (with history) of dementia, from local nursing home, s/p GLF (status post ground level fall). Staff reported patient slipped and fell in the shower, injuring her left lower leg. Xrays were done at the nursing facility, showing left tib/fib (tibia/fibula) fracture. She was admitted for her injuries and evaluated by ortho (orthopedics) who took patient to OR (operating room) for fix on 3/5/22. She did not have any operative complications. She has worked with therapy and achieved pain control. She is tolerating her diet and voiding independently. She is stable for d/c (discharge) to facility . Under Operative Procedures Performed R74's hospital record documents an Open Reduction Internal Fixation of fracture of tibia and fibula. On 05/03/22 at 3:18 PM, V32 (Certified Nursing Assistant/CNA) stated she was working the night R74 fell in the shower and fractured her leg. V32 stated R74 had an episode of incontinence so they were giving R74 a shower. V32 stated R74 had a behavior and swung out a bit and ended up falling. V32 stated they got the nurse, got R74 dressed and into bed, and she believes they either got x-rays at the facility or sent her out to the hospital. When asked about fall interventions for R74, V32 stated they have fun bags to keep her distracted. V32 stated distraction is key for R74. On 5/3/2022 at 2:16 PM, V3 (Unit Coordinator) stated they were having a hard time getting R74 to a therapeutic dose of psychiatric medication. V3 stated R74 is very impulsive and independent. V3 stated R74 swung her body with her feet planted on the ground which resulted in the fracture of her leg and the fall to the ground. R74's facility Event Reports documents the following falls; 2/28/22 5:58 PM, (R74) found in someone else's room at this time. No witnesses to fall. (R74) is free from skin abnormalities/redness at this time. (R74) does not complain of pain .Neurochecks q (every) 4 h (hours) for 24 h initiated. 3/1/22 8:50 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 02/28. Intervention of redirect (R74) when observed in other residents room as tolerated in place to prevent future occurrences. 3/9/22 4:20 PM (R74) was observed sitting on her bedroom floor (R74) was asked if she fell and (R74) stated 'I don't know what happened appeared that (R74) was attempting to put her glass of water on dresser and slid from chair, cup and water were on the floor resident was carrying cup of water previously no new injuries noted resident denies pain to any area neuro checks WNL (within normal limits) . 3/11/22 9:08 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 3/09. Intervention of encourage (R74) to ask for assistance when carrying beverage as tolerated in place to prevent future occurrences. 3/11/22 2:31 PM (R74) had unwitnessed fall in room at this time. (R74) was trying to transfer herself from wheelchair to her bed. (R74) slid onto floor and cannot stand. No rotation or shortening noted and (R74) does not complain of any new pain, just requesting to be picked up off the floor . 3/14/22 8:53 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/11. Intervention of assess footwear in place to prevent future occurrences. 3/20/22 3:52 PM (R74) was observed lying on her bedroom floor (R74) was curled up lying with hands under her head as if sleeping area clean dry free of clutter resident stated 'I was trying to sleep' no new injury noted no deformity rotation or shortening of extremities noted 3/21/22 09:08 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/20. Intervention of encourage (R74) to sleep in bed as tolerated in place to prevent future occurrences. 4/1/22 4:36 PM (R74) found on floor of room at this time. Resident screaming out for 'George.' (R74) on knees at this time and states that she fell . (R74) cannot articulate how or why she fell . (R74's) L (left) lower leg red and warm to touch. (R74) complains of moderate pain to L lower leg. Lower left leg external rotation could be due to boot 4/5/22 X-ray to check status of surgical site. Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 04/01. Intervention in place to dump wheelchair seat. On 05/03/22 at 11:07 AM V16 (LPN/Licensed Practical Nurse) stated she wasn't sure what R74's fall interventions were off the top of her head. V16 stated she was sure it was increased toileting. 2. R10's Resident Face Sheet dated 4/29/22 documents R10 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, unsteadiness on feet, weakness, age-related [CONDITION(S)], vitamin deficiency, cognitive communication deficit, and unspecified [CONDITION(S)]. R10's MDS (Minimum Data Set) dated 4/7/22 documents R10 has a moderate cognitive impairment and requires extensive assistance with bed mobility, transfers, toilet use, and personal hygeine. R10's Care Plan focus documents a problem area for falls with a start date of 04/10/19 as follows - R10 is at risk for falling r/t (related to): Alzheimer's disease, unspecified dementia, unsteadiness on feet, weakness, thyrotoxicosis, cognitive communication deficit, dizziness and giddiness, unspecified [CONDITION(S)], [CONDITION(S)]. [CONDITION(S)] and narcotic medication use. Oxygen use prn. She has history of crawling out bed or wheelchair and sitting on the floor. Goal - Short-term goal target date: 10/08/21 - R10 will have minimal risk for injury related falls. Approach with start dates to include: 04/27/22 - Encourage resident to ask staff for assistance as tolerated; 04/22/22 - assess footwear; 04/08/22 - PT (physical therapy) eval and treat; 04/05/22 - evaluate resident for walking program; 03/30/22 - NP (Nurse Practitioner) to assess; 03/14/22 - anti-roll backs; 03/11/22 - encourage resident to sit on perimeter of dining area during mealtimes as tolerated; 03/07/22 - redirect to quiet area if overstimulated as tolerated; 02/09/22 - encourage R10 to ask for assistance when moving furniture as tolerated; 02/07/22 - offer chore activity near evening meal as tolerated; 01/27/22 - encourage resident to sleep in bed as tolerated; 01/03/22 - encourage resident to ask for assistance when looking for car keys; 12/20/21 - offer sensory activity as tolerated; 11/22/21 - non-slip surface to wheelchair; 11/16/21 - assess wheelchair; 11/10/21 - assess footwear; 11/04/21 - encourage resident to increase foot clearance as tolerated; 10/18/21 - sensory machine at bedtime; 10/12/21 - encourage frequent rest periods as tolerated; 10/05/21 - encourage resident to walk with staff assistance as tolerated; 09/29/21 - scoop mattress; 09/28/21 - non-skid socks; 02/28/21 - visual cues; 09/13/21 - encourage resident to change positions slowly as tolerated; 09/08/21 - reorient to new environment as tolerated; 06/15/20 - redirect if observed going into peers room; 04/10/19 - alternate call lights; 04/10/19; encourage R10 to use side rails and hand rails as needed; 04/10/19 - instruct R10 to call for assist before getting out of bed or transferring. Encourage resident to stand slowly; 04/10/19 - provide R10 with specialized equipment: walker, w/c (wheelchair) as needed. R10's [NAME] Hopkins Fall Risk Assessment Tool documents a score of 30 on 12/30/21 and a score of 26 on 4/14/22 which indicates R10 is at high risk for falls. R10's facility Event Report dated 4/7/22 documents under progress notes, 4/6/22 11:17 PM (R10) up and alert self -propelling via w/c (wheelchair) this evening. (R10) observed by staff trying to stand up out of w/c and walk. (R10) redirected. 4/7/22 03:00 PM (R10) had a witnessed fall by the nurses station. (R10) has been getting up and ambulating without her wheelchair most of the day and has to be continuously reminded to stay in wheelchair. Fall was witnessed by this nurse. (R10) fell on right hip/side and did not hit head. Immediately assessed and pain noted to right groin. Unable to complete ROM (range of motion) due to pain. 2 cm x 1 cm (centimeter) skin tear to right elbow. Steri strips in place V33 (physician) was contacted and notified of findings. Awaiting further orders 4/7/22 03:30 PM Per V33, order received to monitor. 4/7/22 05:09 PM (R10) still complaining of a lot of pain to right hip/groin. V33 notified and ordered x-ray. 4/7/22 06:55 PM Assessment performed on resident upon coming onto shift r/t (related to) fall. (R10) presenting with increase in respirations, guarding right leg; holding right hip/groin and moaning/groaning/whimpering. 'It hurts, it hurts,' with facial grimacing. Has right leg drawn close to body. (R10) unable to extend/move right leg, unable to console/distract/reassure. PAINAD scare score = 9/10 (severe). (Name of local radiology company) contacted for ETA (estimated time of arrival) for STAT (immediate) xray, and they said they did not receive electronic xray order and it'll be 4-6 hours before tech can come to perform xray. DON (Director of Nursing) and POA (power of attorney) notified and okay with transfer to hospital. 4/7/22 07:09 PM (R10) departed via ambulance . 4/8/22 12:00 AM Called (name of local hospital) to get update on resident. Confirmed (R10) fractured right hip; surgery tomorrow 4/8/22 08:58 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 04/07. Intervention of PT (physical therapy) eval (evaluate) and treat in place to prevent future occurrences. R10's local hospital discharge information record documents a hospital stay beginning on 4/7/22 with a diagnosis of closed right hip fracture, closed fracture of first thoracic vertebra, unspecified fracture morphology, and closed displaced fracture of right femoral neck. R10's local hospital record includes a right hip x-ray on 4/7/22 that documents, History: Trauma. Findings: There is an acute displaced fracture of the right femoral neck . R10's local hospital record includes a cervical spine CT (computerized tomography) without contrast dated 4/7/22 that documents the following impression; Study is limited by motion artifact. No acute fracture allowing for limitation by motion artifact. Unchanged mild wedging of C6 vertebral body. Fracture of superior endplate of T1 vertebral body this is new when compared to the prior study similar to the prior study. On 5/03/22 at 9:48 AM V24 (CNA) stated she was working the day R10 fell . V24 stated she was redirecting another resident when the nurse told her R10 had fallen and asked for help. V24 stated R10 was saying her hip hurt. V24 stated it was before dinner and there were three CNA's and a nurse working. When asked if that was enough staff to provide appropriate supervision for the residents V24 stated it was. V24 stated R10 was by the nurses station when she fell . V24 stated R10 forgets she can't walk and attempts to stand up out of her wheelchair and staff have to remind her to sit down. V24 stated she didn't have any concerns with the care that was provided to R10 after she fell . When asked what interventions were in place to prevent falls V24 stated they keep R10 by the nurse's station when they can and sit next to her at meals. V24 stated they provide 1:1 interaction after dinner when behaviors are more likely. V24 stated she wasn't aware of any specific fall interventions for R10. V24 stated all of the residents wear no slip socks and they are checked at least every two hours for toileting. On 05/03/22 at 11:07 AM V16 (Licensed Practical Nurse/LPN) stated she was working the day R10 fell . V16 stated she was sitting inside the nurse's station and R10 was in her wheelchair sitting outside of the nurse's station. V16 stated R10 had been redirected to stay in her wheelchair and then R10 attempted to stand up and fell . V16 stated R10 was complaining of pain and was transferred to the local hospital for evaluation. R10's facility Event Reports documents the following falls: 1/2/22 Staff found (R10) on dining room floor (R10) stated 'I was trying to walk to find my husband and my car keys.' Area clean dry and free of clutter, hematoma noted to left elbow/forearm no deformity rotation or shortening of extremities noted neuro checks WNL .encouraged to request assistance when needing or wanting to ambulate . 1/3/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 01/02/22. Intervention of encourage (R10) to ask for assistance when looking for car keys in place to prevent future occurrences. 1/31/22 05:07 AM-At approx 0445 (4:45 AM), noise heard from (R10's) bedroom. R10 found on the floor next to her bed. Bed was in lowest position with call light in reach. (R10) doesn't remember how she fell .Hematoma noted to R (right) side of head. 1 cm (centimeter) x 1 cm bruise R bridge of nose and small cut. 1 cm x 1 cm bruise R check. 2 cm x 1 cm ST (skin tear) right elbow . 2/1/22 01:24 AM x-ray obtained .resident compliant. 2/1/22 03:46 AM xray results received and subacute nondisplaced distal clavicle fracture' V33 informed awaiting further orders. 2/1/22 04:02 PM Order received for resident to wear a sling to right arm. 2/7/22 12:04 PM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 1/31/22. Intervention of body pillow in place to prevent future occurrences. 1/31/22 5:56 PM (R10) fell again this evening, same presentations as previous fall. Vitals WNL. 2/7/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 01/31/22. Intervention of offer chore activity near evening meal time as tolerated in place to prevent future occurrences. 2/8/22 (R10) was in dining room when she stood up from wheel chair and attempted to move furniture (R10) then fell backwards landing on her buttocks before this writer could react to her and prevent fall. Area clean, dry, and free of clutter, no rotation, deformity, shortening or lengthening of extremities noted. (R10) has an abrasion and 2 cm diameter hematoma to lateral left knee. (R10) did not hit her head. (R10) did bite her top lip- lip bifurcated approx 0.5 cm in length 2/9/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 2/8/22. Intervention of encourage (R10) to ask for assistance when moving furniture as tolerated in place to prevent future occurrences. 3/3/22 (R10) had unwitnessed fall at nurses station at this time. (R10) appears to have been ambulating without assistance. Wheelchair near by. (R10) is sitting on bottom with back to nurses station leaning against counter. Skin tear to left elbow measures 9 cm (centimeter). Skin flap able to be repositioned over wound. Cleansed, steri strip, and boarder gauze applied. (R10) able to move all extremities without difficulty. No other obvious signs of injury or deformity, able to move all extremities without difficulty . 3/7/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/03. Interventions of redirect to quiet area if overstimulated as tolerated in place to prevent future occurrences. 3/9/22 (R10) was at dining room table and attempted to stand (R10) tripped over her foot causing her to fall before staff was able to reach her. Area clean, dry, free of clutter, no deformity rotation or shortening of extremities. (R10) did hit the left side of her head resulting in a hematoma left mid scalp and also has redness to left forehead/temporal area .(R10) encouraged to request assistance when wanting to stand or transfer . 3/11/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/09. Intervention of encourage resident to sit on perimeter of dining area during mealtimes as tolerated in place to prevent future occurrences. 3/13/22 (R10) was observed lying on the floor at nurses station area clean dry free of clutter appeared (R10) was attempting to stand from WC (wheelchair) no injury noted no rotation deformity or shortening extremities noted 3/14/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/13. Interventions of anti roll backs in place to prevent future occurrences. 3/29/22 (R10) had witnessed fall at this time. (R10) did not hit her head. (R10's) ROM are within normal limits. ST (skin tear) to R elbow noted upon inspection 3/30/22, Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/29. Intervention of NP (Nurse Practitioner) to assess in place to prevent future occurrences. 4/3/22 (R10) was observed sitting on the floor in front of door of kitchenette. (R10) stated 'I was trying to walk over yonder', area clean dry and free of clutter. (R10) denied hitting her head however a 2 cm (centimeter) diameter hematoma was noted to left side back of head. No rotation deformity shortening of extremities noted. No other injury noted . (R10) laughing and smiling. (R10) denies pain. (R10) encouraged to request assistance when wanting to transfer or ambulate .4/15/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 04/03. Intervention in place to evaluate (R10) for walking program. 4/21/22 (R10) had an unwitnessed fall in room. (R10) was found sitting on the floor by her bed. Bed in lowest position. (R10) immediately assessed and no injuries found. (R10) assisted back to bed and was educated on the importance of not getting up without help. (R10) showed understanding. ROM completed and WNL but limited to RLE (right lower extremity) due to recent fx (fracture) 4/26/22 (R10) was observed lying on floor in dining room, area clean dry free of clutter. No deformity rotation or shortening of extremities noted . (R10) has a 2.5 cm diameter hematoma to back of mid scalp neuro checks wnl for (R10). (R10) encouraged to use wc (wheelchair) or request for assistance for transferring 4/27/22 10:21 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 04/26. Intervention of encourage resident to ask staff for assistance as tolerated in place to prevent future occurrences On 04/26/22 at 11:02 AM, this surveyor was in the dining room screening residents, when this surveyor turned around and saw R10 laying on the floor in the dining area in front of the resident rooms with a pillow under her head. V17 (LPN) was observed assessing R10. R10's wheelchair was sitting next to her. R10 was transferred to her wheelchair with three staff using a mechanical lift appropriately. There were no obvious signs of distress observed. On 4/29/22 at 9:43 AM, V20 (CNA) stated the interventions staff implement for fall prevention for R10 are to keep her out of her room as much as possible and R10 prefers that. V20 stated they also check on R10 frequently. On 05/03/22 at 8:45 AM when asked what interventions were in place to prevent falls, V22 (CNA) stated if residents are not in bed they take them to the nurse's station and do an activity with them. V22 stated they do bed checks every two hours and check on R10 more often than that. When asked how often they check on R10, V22 stated they try to check on R10 every 30 minutes. On 05/03/22 at 2:16 PM, V3 (Unit Coordinator) reviewed R10's falls and interventions and stated R10 is very delusional. V3 stated one second R10 is checking on her grandma and the next second R10 is going to work. V3 stated this can change within a minute. When asked if encouraging R10 to ask for assistance was an appropriate intervention if R10 is delusional and has a diagnosis of dementia, V3 stated R10 is still rational. V3 stated R10 gets set on a task so you help her with the task she is on. V3 stated R10 will get your attention if needed. 3. R69's facility Resident Face Sheet dated 4/29/22 documents R69 was admitted to the facility on [DATE] with diagnoses that include unspecified fracture of right pubis, unspecified dementia, mild cognitive impairment, unspecified displaced fracture of surgical neck of left humerus, repeated falls, brief [CONDITION(S)], and dementia. R69's MDS dated [DATE] documents R69 has a BIMS score of 03, which indicates R69 has a severe cognitive impairment. R69's MDS documents under Section G R69 requires assist of one staff for bed mobility, transfer, walking, locomotion, toileting, and personal hygeine. R69's MDS documents under Section J that R69 has had falls with major injury since admission to the facility. R69's [NAME] Hopkins Fall Risk Assessment Tool dated 2/25/22 documents R69 has a fall risk score of 22 which indicates R69 is at high risk for falls. R69's Care Plan focus documents a problem area for falls with a start date of 09/16/20 as follows - R69 is at risk for falling r/t recent illness/hospitalization and new environment. R69 sits on floor, hides under tables, furniture, attempts to sleep on the floor, runs, and prays while on her knees. Goal target date: 10/01/21 - R69 will have decreased risk for injury related to falls this quarter. Approach with start dates to include: 04/18/22 - visual cues in resident bathroom; 04/13/22 - encourage resident to use arms of chair to lower self into chair as tolerated; 03/28/22 - treat underlying condition; 03/07/22 - assess wheelchair; 02/28/22 - alternate call light; 02/25/22 - visual cues in resident room; 02/22/22 - assess resident for soft collar to improve posture to decrease loss of balance as tolerated; 02/07/22 - encourage resident to ask for assistance when changing clothes as tolerated; 02/07/22 - PT and treat; 01/27/22 - med review; 11/19/21 - encourage resident to not reach past base of support; 09/16/20 - assist resident with activities of interest; 09/16/20 - encourage resident to use side rails/enablers as needed; 09/16/20 - instruct resident to call for assist before getting out of bed or transferring. Encourage resident to stand slowly. R69's Event Report dated 2/27/22 documents under progress notes, 2/27/22 02:57 PM (R69) was found on her bedroom floor. (R69) stated she 'slipped' area clean dry free of clutter. 6.5 cm laceration to right side forehead with moderate amount of bleeding noted. Edges of laceration unable to be approximated due to missing skin flap no other injury noted. No deformity rotation or shortening of extremities noted . (R69) denies pain . Ambulance called for transport to (name of local hospital) for probable sutures. Direct pressure applied to wound and (R69) observed until EMT's (Emergency Medical Technicians) arrived 2/27/22 06:37 PM (R69) returned back to facility from hospital at approx (approximately) 5:55 pm; q4h (every four hours) neuro checks entered WNL, no s/s (signs or symptoms) or c/o (complaints of) pain at this time; sutures to right forehead with dry dressing in place. 2/27/2022 10:41 PM CT (computerized tomography) of head and spine were done at hospital. 2/28/2022 01:19 AM (R69) resting in bed with no s/s or c/o pain/distress . 02/28/2022 08:58 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 02/27. Intervention of alternate call light in place to prevent future occurrences. 3/5/2022 02:30 PM (R69 has slept most of shift sutures to forehead intact no warmth drainage or swelling noted, scheduled [MEDICATION(S)] 5-325 has been effective for pain control no complaints of pain due to fractures of pelvic ramus. R69's Event Report dated 4/17/22 documents under progress notes, 4/17/2022 12:38 AM CNA (Certified Nursing Assistant) on hall discovered (R69) on floor sitting on buttocks in bathroom. Prior to fall (R69) noted to be in bed with call light in reach. (R69) did not use the call light for assistance. (R69) continues to self transfer and self ambulate. Staff unaware (R69) up in bathroom (R69) voice c/o pain to left hip MD (physician) notified with request for an order to x-ray. Will continue to monitor. 4/17/2022 01:30 AM MD responded with okay to obtain x-ray. 04/17/22 04:32 AM x-rays completed at this time. 04/17/2022 10:00 PM (name of local radiology company) contacted for xray results. X-rays were performed to the left arm and left hip. #1 Left humerus- displaced left surgical neck humeral fracture. #2 Left hip-Chronic fracture of the ischium, displaced fracture of the inferior right pubic bone. Present on previous study but more displaced now. V33 (Physician) contacted and advised this nurse with the following- May ambulated as tolerated. Needs to see orthopedic, can wait until tomorrow. Sling needs to be worn R69's facility x-ray reports document on 3/1/22 under impressions: 1. Acute mildly displace fracture of medial right superior pubic ramus and acute non-displaced impacted fracture of inferior right pubic ramus . On 04/28/22 at 9:55 AM, an alternate call light was observed on R69's bed. R69 was observed wearing a sling on her left arm, sitting in a wheelchair next to her bed, brushing her hair. Visual cues were observed in the bathroom to use the call light when getting up. On 04/29/22 at 1:34 PM, V17 (Licensed Practical Nurse/LPN) stated she remembered a CNA (unknown) telling her R69 was on the floor. V17 stated R69 said she had slipped and was always trying to go to the bathroom by herself. V17 stated they have two or three CNA's and one nurse working on night shift and that is enough staff to supervise the residents and prevent falls. V17 stated residents are all checked every two hours while in bed. When asked what fall preventions were in place for R69, V17 stated they do more frequent checks on her and have R69 sit where they can see her. When asked how often R69 is checked on, V17 stated she wasn't sure. On 05/03/22 at 3:09 PM, V31 (LPN) stated she was working when R69 fell . V31 stated R69 was up walking around all night. V31 stated they kept redirecting R69 but they can't force them to stay still. V31 stated R69 was finally in bed and then was found in the bathroom by the CNA's. When asked how often staff check on R69 on midnight shift V31 stated she knew they did two rounds and she was typically checking on residents also. V31 stated there wasn't any certain protocol on how often R69 was checked. V31 stated R69 had been checked about 30 minutes prior to the fall when V31 helped R69 to the bathroom. When asked if she was familiar with R69's fall interventions V31 stated, Just visual cues. When asked what she meant by visual cues V31 stated that is what the chart says. V31 stated she was assuming it meant if you see R69 try to redirect her or assist her. V31 stated she always reminds her to use her call light and she (R69) will sometimes use it. On 04/29/22 at 2:24 PM, V18 (Certified Nursing Assistant/CNA) stated he was working one time when R69 fell but was unable to remember when it was. V18 stated R69 usually falls on day shift or midnight shift. V18 stated he thinks R69 was by her bed and she probably fell trying to get in or out of the bed. V18 stated R69 always falls by her bed and that R69 never falls in her bathroom. R69's facility Event Reports document the following falls: 1/24/22 At approx. (approximately) 0525 (5:25 AM) noise heard near nurses station, resident (R69) observed by CNA holding onto a kitchen cart with wheels and fell down onto floor, on right side, hitting head, large hematoma observed to right head; ice applied to site. VS, ROM, neuro WNL for (R69) . 1/27/22 08:46 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 1/24/22. Intervention of med review in place to prevent future occurrences. 2/5/22 (R69) was fou [TRUNCATED]

Based on interview and record review, the facility failed to ensure treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R226 experiencing uncontrolled pain after admission and while participating in the therapy program, ultimately going 4 days without receiving a narcotic as ordered for pain control. Findings Include: R226's out of state hospital record documents a hospital admitted [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R226 was discharged from the hospital to this facility on 04/15/22 with discharge medication orders to include [MEDICATION(S)] 100mcg/hr (microgram/hour), place 1 patch on the skin every third day for 6 days for severe chronic pain with opioid tolerance, start date 04/16/22. R226's resident face sheet dated 4/29/22 documents admission to this facility on 04/15/22 with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R226's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R226's facility POR (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] R226's April 2022 MAR (Medication Administration Record) documents in part - Assess pain every shift using 0-10 scale or verbal descriptor scale to begin on 04/19/22. R226 was assessed to have experienced the following pain - 04/19/22 - generalized at a 6 on day shift and 7 on evening shift; 04/20/22 no pain on day shift and leg pain at a 7 on evening shift; 04/21/22 documents R226 is having no pain this day; 04/22/22 hip, back, and left leg pain at an 8 on day shift, and moderate generalized pain on evening shift; 04/23/22 generalized pain at a 7 with no pain on the evening shift; 04/24/22 no pain on day shift and leg pain at a 7 on the evening shift; 04/25/22 all over pain on day shift at an 8 with generalized pain at a 6 in the evening; 04/26/22 no pain on day shift with leg pain at a 5 on evenings; 4/27/22 documents no pain. R226's [MEDICATION(S)] 100mcg patch every 72 hour was documented as not administered from 04/16/22 to 04/19/22 due to not being available. A progress note dated 04/18/22 at 4:42 PM documents - Signed Rx (prescription) for [MEDICATION(S)] patches sent to CCP (critical care pharmacy) at this time. NP (Nurse Practitioner) gives one time order for 50mcg patch until 100mcg is delivered. 50mcg patch pulled from stat-safe . A progress note dated 04/18/22 at 4:52 PM documents [MEDICATION(S)] 50mcg was pulled from the stat safe and applied to R226's right shoulder, which is half the physician ordered dose. A progress note dated 04/19/2022 at 03:24 PM documents a [MEDICATION(S)] 100mcg patch was administered to R226. There is no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] R226's POR dated 3/28/22 to 4/28/22 also documents - [MEDICATION(S)] patch 72-hour 100mcg/hr 1 patch transdermal for leg pain every 3 days, start date 04/21/22. R226's April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R226's progress note dated 04/24/2022 at 2:02 PM documents - Resident out of [MEDICATION(S)] 100mcg/hr patch. Pharmacy called for e-pull. Order faxed . Awaiting call back. R226's progress note dated 04/24/2022 at 9:54 PM documents - [MEDICATION(S)] 100mcg patch unavailable in stat safe. Only one 50mcg available and placed on residents right upper arm. This dose is not documented on R226's April MAR. R226's progress note dated 04/26/22 documents the resident is out of [MEDICATION(S)] 100mcg and unavailable in the facility stat safe. The facility documented [MEDICATION(S)] 50mcg was available and was placed on R226's arm on 04/26/22, half the ordered dose. This dose is not documented on R226's April MAR. R226's April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/27/22 at 9:30 AM, R226 stated he admitted to this facility from an out of state hospital after undergoing surgical repair of left hip. He stated it took several weeks for the hospital to get his pain under control and manageable. He stated he discharged to this facility for after care and therapy in hopes to go home when he gets stronger. R226 stated when he first got here on 04/15/22, his pain medications were messed up and he did not get his [MEDICATION(S)] patch the first several days. He confirmed he did participate in therapy, but it was rough because he was in so much pain. He stated he didn't quit, though. R226 stated that he believes his [MEDICATION(S)] got straightened out, but it took about another week to get his pain under control, and he began to feel better on 04/25/22. On 04/29/22 at 2:30 PM, V2 (Director of Nursing - DON) stated R226's [MEDICATION(S)] 100mcg prescription was originally sent to the wrong pharmacy by the out of state discharging hospital causing a delay in the administration of this pain patch to the resident. On 05/03/22 at 3:10 PM, V28 (Physical Therapy Assistant - PTA) stated R226 told to him there was an issue with the facility getting his pain medication initially but thought this had been taken care of a few days after admission. V28 stated R226 was in a lot of pain when he began therapy and did report this to V28. On 05/04/22 at 10:21 AM, V2 (DON) verified V25 (Family Member) brought in [MEDICATION(S)] patches picked up at the local pharmacy on 04/18/22, but they were 75mcg only, so the facility continued to pull [MEDICATION(S)] 50mcg from the stat safe. V2 stated he believed R226's pain was partially covered by giving the half dose of 50mcg available and thought the facility would have gotten approval from a nurse practitioner, physician, or on call clinician upon administration of [MEDICATION(S)] 50mcg on 04/18, [MEDICATION(S)] 100mcg on 04/19, [MEDICATION(S)] 100mcg on 04/21, [MEDICATION(S)] 50 mcg on 04/24, [MEDICATION(S)] 50mcg on 04/26, and [MEDICATION(S)] 100mc on 04/27 since this was not administered as prescribed, but was not able to provide corroborating documentation of obtaining the approval. On 05/04/22 at 1:00 PM, V30 (Nurse Practitioner) stated she spoke with the facility on 04/18/22 and gave verbal approval to administer a 50mcg [MEDICATION(S)] patch to R226 since the 100mcg prescription was still not available. V30 stated she was not involved in giving approval for R226 to receive [MEDICATION(S)] 100mcg on 04/19, [MEDICATION(S)] 100mcg on 04/21, [MEDICATION(S)] 50 mcg on 04/24, [MEDICATION(S)] 50mcg on 04/26, and [MEDICATION(S)] 100mcg on 04/27 and would have expected the facility to contact the physician to get approval to do so since this was not administered as prescribed. The facility Pain Management Policy dated 09/10 documents, The Facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy Procedure: 1. Residents will be assessed for pain using the Geriatric Pain Assessment upon admission, quarterly and with any significant change in resident condition. A standardized 0-10 scale of Verbal Descriptor Scale (VDS) will be utilized to determine pain intensity. 2. The physician will then be contacted, if needed, regarding the pain or pain indicators. Licensed staff will document any contact with the physician and the physician's response. 3. An individualized care plan will be developed and implemented. 4. If the resident's pain is not being controlled, a Pain Tracking Log may be implemented to track pain and response to medication and/or treatment. 5. Residents will be monitored until pain is resolved or is under control and periodically thereafter. 6. Licensed staff will document any complaints of pain and the resident's response to the medication/treatment in resident's record. 7. In the event that there are no new medication orders from the physician, licensed staff will continue to monitor the resident's condition, keeping the primary physician informed. 8. The Medical Director will be notified of resident's condition, physician notification and lack of response, should that occur. 9. Alternative methods of pain control will also be attempted .

Based on observation, interview, and record review the facility failed to follow therapeutic dietary recommendations for residents with significant weight loss; and failed to implement medication prescribed specifically for weight loss for 4 of 7 (R9, R69, R72, R74) residents reviewed for weight loss in a sample of 47. This failure resulted in R72 having an 8.41% (severe weight loss) in a period of just over 1 month, R9 having a 12.3% weight loss in six months, and R69 having a 5.4% weight loss in one month and a 17.8% weight loss in six months. Findings Include: 1. R9's Resident Face Sheet dated 4/29/22 documents R9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's MDS (Minimum Data Set) dated 4/5/22 documents R9 has severely impaired cognitive skills and requires one person physical assist to eat. R9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's facility care plan dated 7/14/21 documents a problem area of Resident requires assistance with eating and putting on shirt related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Set meal up completely, instruct resident to feed self, if he/she does so reward with praise. If not move to next step, Step 2. Place utensil in resident's hand, instruct to put food on utensil and place into mouth. If he/she does so reward with praise. If not, move to next step. Step 3. Place hand over resident's hand, filling utensil with food and guiding to resident's mouth. If he/she does so reward with praise. If not move to next step. Step 4. Place food on residents utensil and put food into resident's mouth, tell resident to chew then swallow after each bite. If he/she does so reward with praise. R9's care plan does not address weight loss and/or interventions to prevent weight loss. R9's dietitian assessment dated [DATE] documents, On a regular diet with high calorie supplement. Fortified pudding at lunch and supper and fortified whole milk at meals. Intakes 25-50%. Refusing meals at times. On [MEDICATION(S)]/[MEDICATION(S)] which can increase/stimulate appetite Weights: (4/1): 107, (3/1): 106, (1/3): 119, (12/31):119, and (10/4): 122. Current weight is down 12# (pounds) (10.1%) x 88 days, down 12# (10.1%) x/3 (times 3) months, and down 15# (12.3%) x/6 months. Below IBW (Ideal Body Weight) Range 132-166. Body Mass Index: 16.27 (Underweight- However with [CONDITION(S)] not a true indicator of risk). Has 2+(plus) Bilateral LE (lower extremity) [CONDITION(S)], (diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin free of open areas Continue with diet Rx (prescription) as weights up 1# x/1 month. Monitor. R9's Vitals Report dated 11/01/21 to 4/29/22 documents the following weights; 11/03/21- 124 pounds, 12/01/21-109 pounds, 1/3/22- 119 pounds, 2/2/22-103 pounds, 4/1/22- 107 pounds, 4/29/22- 116 pounds. On 4/28/22 beginning at 11:42 AM, R9 was served lemonade and fortified milk, chicken, roasted red potatoes, broccoli, and bread. R9's meal card observed lying on the table next to his tray documented R9 was to have gotten a regular diet with a high calorie supplement, and fortified mashed potatoes. R9 was not served mashed potatoes. On 4/28/22 at 12:20 PM V27 (Dietary Assistant) stated R9 should have received fortified mashed potatoes with his noon meal on 4/28/22. On 04/28/22 at 2:15 PM V4 (Dietary Manager) stated R9 should have been served fortified mashed potatoes. 2. R69's Resident Face Sheet dated 4/29/22 documents R69 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R69's MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 03, which indicates R69 has a severe cognitive impairment. R69's MDS documents under Section G that R69 requires physical assist of one person for eating. R69's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R69's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R69's Dietitian assessment dated [DATE] documents, On a regular diet with Fortified Mashed Potatoes at Lunch/Supper. Ice Cream at lunch and supper. Ensure TID (three times daily) provided by family. Intakes 25-75%. On [MEDICATION(S)] which can increase appetite .Weights (4/1): 88, (3/1): 93, (1/1): 98.2, and (10/4): 107. Current weight is down 5# (pounds) (5.4%) x/1 (times 1) month, down 10# (10.4%) x/3 months, and down 19# (17.8%) x/6 months. Below IBW (ideal body weight) Range 102-131. Body Mass Index 16.09 (Underweight) Continue with diet Rx. (prescription) Monitor. R69's Vitals Report dated 11/01/21 to 4/29/22 documents the following weights; 11/03/21-100.1 pounds, 12/01/21- 97 pounds, 1/1/2022- 98.2 pounds, 2/2/22- 93 pounds, 3/1/22- 93 pounds, 4/1/22- 88 pounds, 4/28/22- 96 pounds. R69's Care Plan dated 10/01/21 documents a problem area of Resident requires assistance with putting on shirt and eating related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions listed for this problem area are, Eating program: Step 1: Set meal up completely, instruct resident to feed self. If he/she does so, reward with praise. If not, move to the next step. Step 2: Place utensil in resident's hand, instruct to put food on utensil and place into mouth. If he/she does so, reward with praise. If not, move to next step. Step 3. Place hand over resident's hand, filling utensil with food and guiding to resident's mouth. If he/she does so, reward with praise. If not, move to next step. Step 4: Place food on resident's utensil and put food into resident's mouth, tell resident to chew then swallow after each bite. If he/she does so, reward with praise. R69's care plan does not document a problem area and/or interventions to prevent weight loss. On 04/26/22 at 12:12 PM, R69 was served roast turkey and gravy, mashed potatoes, mixed vegetables, bread, butter, and an eclair. R69 was observed feeding herself and no supplements were observed served to R69. On 4/28/22 beginning at 11:42 AM, R69 was served lemonade, broccoli with cheese on it, red roasted potatoes, meat (chicken), bread, and cream pie. R69 was not served an ensure, mashed potatoes, or ice cream with this meal. R69's meal card documented she should have been served fortified mashed potatoes. On 04/28/22 at 9:05 AM V19 (Certified Nursing Assistant/CNA) stated R69 was given ensure when she asked for them which was usually after lunch. V19 stated the ensure was provided for R69 by her family. On 4/28/22 at 2:21 PM V26 (Resident Assistant) stated R69 gets the ensure when she asks for them. When asked how often she gets ice cream, V26 stated they just give them to her when she asks for them. When asked if she gets the ice cream and ensure with each meal, V26 stated she usually asks for Coke. V26 stated it is not documented anywhere when they give her the ensure or the ice cream. On 4/28/22 at 2:31 PM V24 (CNA) stated R69 gets ensure when she asks for them. When asked how often R69 asks for them V24 stated she asks for them with each meal. When this surveyor confirmed R69 asks for ensure and ice cream with each meal, V24 stated she was only with R69 during one meal a day (supper) and she (V24) tries to remember everyday but sometimes when it is chaotic it gets missed. On 4/29/22 at 9:43 AM, V20 (CNA) stated they used to document giving the ensure and ice cream under the snack section but that got discontinued. V20 stated she usually gives R69 an ensure at breakfast and lunch but sometimes R69 won't drink it and she gives R69 the ice cream whenever she asks for it. On 04/29/22 at 1:46 PM, V17 (LPN/Licensed Practical Nurse) stated R69 doesn't eat much so they started giving her ensure. V17 stated the order is for meal times but she usually asks for them in between meals. V17 stated they give them to her when she asks for them. When asked if there was a system in place to ensure R69 gets them when she didn't ask for them, V17 stated R69 has never had a problem asking for them. V17 stated she asks for them at least three times a day and sometimes more. When asked if it was documented anywhere, V17 stated she didn't think so. On 4/28/22 at 2:48 PM, V3 (Dementia Unit Coordinator) stated R69 gets ensure for significant weight loss and R69's family supplies it. V3 stated R69 has had some mental health issues and she was sent out for a psychiatric evaluation and wasn't taking anything by mouth. When asked if there was anyway the facility was tracking to ensure R69 was offered and/or served ensure and ice cream as ordered/recommended, V3 stated she wasn't sure and she would have to check to see if there was anyway they were tracking it. On 4/28/22 at 12:20 PM, V27 (Dietary Assistant) stated she served regular mashed potatoes today because they didn't have any fortified mashed potatoes brought to them by the kitchen. When asked if she let the kitchen know she didn't get fortified mashed potatoes to serve, she said she hadn't. V27 stated they didn't serve fortified mashed potatoes to anyone for the noon meal on 4/28/22. V27 stated R9 and R69 should have both received fortified mashed potatoes. On 04/28/22 at 1:59 PM, V4 (Certified Dietary Manager) stated they did not have fortified mashed potatoes to serve R9 and R69. V4 stated they should have had them and they didn't. V4 stated she told V27 all she had to do was call the kitchen when that happened. When asked about R69's supplements, V4 stated they try to change it up and they usually keep ice cream in the freezer. When asked how she ensures R69 is getting the supplements every day V4 stated she should. V4 stated the CNA's (Certified Nursing Assistants) should offer it. V4 stated she did not have R69 on ensure. V4 stated dietary is not allowed to give ensure because it is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/4/22 at 9:50 AM, V29 (Dietician) stated she is not sure if there is a system in place to ensure R69 gets the ensure and ice cream as ordered/recommended. V29 stated she doesn't have any concerns the residents have not been getting supplements routinely but they should have been served fortified mashed potatoes with the noon meal as recommended. 3. R72's Face Sheet documents admission to this facility on 03/03/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R72's admission weight dated 03/03/2022 is documented at 90.4lbs (pounds) with a BMI (body mass index) of 17.65. A progress note dated 04/19/2022 at 4:45 PM documents V5 (Primary Care Physician - PCP) ordered [MEDICATION(S)] 2.5 mg (milligram); bid (twice daily) 1 hour before lunch and dinner. R72's POS (Physicians Order Sheet) documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date: 04/20/22. A progress note dated 04/20/22 at 10:03 AM documents [MEDICATION(S)] rx (prescription) faxed to V5 at this time awaiting signature. A progress note dated 04/27/22 at 12:02 PM documents the facility contacted V5's office regarding the [MEDICATION(S)] ([MEDICATION(S)]) prescription - Office states they will be sending a signed script today. R72's April 2022 MAR (Medication Administration Record) documents [MEDICATION(S)] 2.5 mg was not administered due to drug not being available from 04/20/22 to 04/28/22. R72's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R72's record dated 04/19/22 documents a weight of 82.8lbs with a BMI of 16.17. This shows an 8.41% weight loss in 6 weeks, indicating a severe weight loss. On 04/29/22 at 11:54 AM, V2 (DON - Director of Nursing) stated when the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 acknowledged a week passed before the facility contacted V5's office to follow-up on R72's prescription for [MEDICATION(S)]. V2 confirmed R72's [MEDICATION(S)] still had not been received and administered to R72 for weight loss. V2 stated he would expect the nurses to follow-up across shifts to verify resident medications are in place and being administered timely and as ordered. 4. R74's Resident Face Sheet dated 4/29/22 documents R74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R74's 3/14/22 Minimum Data Sheet (MDS) section C showed a Brief Interview for Mental Status (BIMS) score of 2, showing severe cognitive impairment and section G showing supervision and setup only with eating. R74's Electronic Medical Record (EMR) did not show any care plans for weight loss. R74's EMR showed a 4/9/22 dietary progress note . On a Regular diet with High Calorie High Protein Supplement . Resides on . where additional snacks available between meals . Weights: (4/1): 95, (3/1): 106, (1/3): 103, and (10/4): 108. Current weight is down 11#(10.4%) x/1 month, down 8#(7.8%) x/3 months, and down 13#(12.0%) x/6 months. Below IBW Range 105-134. Body Mass Index: 16.83 (Normal/ Healthy Weight) .PLAN: To stabilize weights. 1). ADD: Fortified Pudding at lunch and supper. On 05/03/22 at 11:41 AM, V14 (Licensed Practical Nurse/LPN/Care Plan Coordinator/CPC) said any resident with severe weight loss should have a care plan with interventions including monitoring monthly or more frequent weights, monitoring of food intake percentages, and monitoring dietary supplement intake. V14 said if a resident has significant weight loss and does not have a care plan for weight loss the likely outcome will be no correction of the problem and the resident will continue to lose weight.

Based on observation, interview, and record review the facility failed to accurately assess and treat pain for 2 of 4 (R2 and R14) residents reviewed for pain in the sample of 16. This failure resulted in R2 and R14 having untreated and/or uncontrolled pain. R2 was unable to participate in therapy as ordered as a result of the pain and R14 who was on comfort care measures went approximately 24 hours without receiving an ordered narcotic for pain control. Findings Include: 1. R14's facility face sheet dated 3/3/22 documents R14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R14's care plan dated 2/28/22 documents a problem area of comfort care related to lymphocytic [CONDITION(S)] with approaches that include, Provide pain management. Administer nonpharmacological pain relief interventions as well as medication as ordered. R14's progress notes document the following: 2/26/22 1:00 PM R14 arrived to the facility via ambulance. 2/26/22 2:12 PM . Resident is A/O (alert and oriented) x 4 (times four). 2/27/22 4:11 PM Resident and resident's family has decided upon comfort care measures. POA (power of attorney), V34 agreed at this time. Resident wants all medications d/c'd (discontinued) and medications just make her pass the times because she's ready to go. 2/28/22 1:21 PM NP (nurse practitioner) orders PRN (as needed) [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] at this time. Orders processed. R14's progress notes do not document assessment and/or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/1/22 at 11:59 AM during a medication administration observation, V6 (RN/Registered Nurse) stated R14 was on comfort care measures and was having pain. V6 stated R14 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 stated R14 had been awake since 10:00 AM and had been asking for pain medication since that time. V6 stated the only other medication R14 had ordered for pain was Tylenol. When asked if he had administered Tylenol V6 stated he had not but he had given R14 [MEDICATION(S)] and R14 had said it would be fine. Upon entering R14's room with V6 at this same time R14 was observed lying in bed and appeared restless. R14 stated she was hurting. V32 (private caregiver) was at R14's bedside and stated R14 had been asking for pain medication since 9:30 AM. V6 stated pain should be a top priority and asked R14 if she was in pain and if she still wanted the [MEDICATION(S)]. R14 stated she was in pain and would like [MEDICATION(S)]. V6 was observed administering Tylenol 325 mg (2) tablets to R14. On 3/2/22 at 10:14 AM V32 (private caregiver) stated she came to the facility on [DATE] around 9:00 AM and R14 was screaming, pain pill. V32 stated R14 said her bottom was hurting. V32 stated when she told V6 (RN) R14 was in pain she was told it wasn't time for R14's pain medication yet. V32 stated R14 cried out in pain for two more hours. V32 stated unknown staff came in multiple times and told them it wasn't time for R14 to get pain medication yet. V32 stated R14's family (V34) told her they were giving R14 [MEDICATION(S)] and couldn't give her the [MEDICATION(S)] because they didn't have the code or something. On 3/1/22 at 4:00 PM R14 was observed lying in bed and appeared restless and stated she was in pain and needed pain medication. V6 was observed in the hall outside R14's room and stated he had given her [MEDICATION(S)], but he would need to let the doctor know she was still having pain since the dose she was on was so low. R14's medical record reviewed from 3/1/22 to 3/3/2022 does not document R14's physician was notified. R14's Medication Administration History dated 3/1/22 to 3/3/2022 documents Tylenol 325 mg (2) tablets was administered on 3/1/22 at 12:08 PM and [MEDICATION(S)] 0.25 ml was administered on 3/1/22 at 1:12 PM, 4:15 PM, and 7:21 PM. R14' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/2/22 at 10:12 AM R14 was observed lying in bed. R14 stated she was in pain and had been in pain. R14 was not able to describe her pain or say how long she had been in pain. On 3/2/22 at 3:55 PM V35 (CNA/Certified Nursing Assistant) stated she had been at work since 2:00 PM and R14 had complained of pain since she had been there. V35 stated V25 (RN) gave R14 pain medication, and they had her pain under control. On 3/3/22 at 2:37 PM V22 (Resident Assistant) stated on 3/2/22 R14 was on her call light a lot and saying she needed pain medication. V22 stated she would go to the nurse and tell her, and she remembered one nurse (unknown) told her she had just given R14 pain medication. When asked about non-pharmacological pain interventions the facility implemented V22 stated since R14 was on comfort care measures and didn't get out of bed much they would reposition R14 and use pillows for support. On 3/2/22 at 3:58 PM V25 (RN) stated she was R14's nurse today (3/2/22). V25 stated R14 was comfortable today 3/2/22 and had not yelled out. R14's Medication Administration History dated 3/1/22 to 3/3/2022 documents [MEDICATION(S)] 0.25 ml was administered on 3/2/22 at 2:44 PM. There is no other documentation of R14 being administered pain medication ([MEDICATION(S)] or Tylenol) on 3/2/22. R14' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/2/22 at 10:18 AM V33 (private caregiver) stated she was in the facility visiting with R14 over the weekend (2/26/22 and 2/27/22) and R14 was uncomfortable and not sleeping well. V33 stated R14 hadn't started comfort care measures at that point, and they did ask for pain medication, but she wasn't sure what R14's medication orders were over the weekend. R14's Medication Administration History dated 2/1/22 to 2/28/22 documents R14 was administered Tylenol 325 mg (2) tablets on 2/27/22 at 2:35 PM and on 2/28/22 at 10:03 PM. R14's medication administration history does not document administration of [MEDICATION(S)] 0.25 ml after it was ordered on 2/28/22. R14's medication administration history documents R14 was assessed as not being in pain on each shift on 2/26, 2/27, and 2/28/22. On 3/2/22 at 3:58 PM V25 (RN) stated she provided care to R14 on 2/27/22. V25 stated she did not remember R14 being in pain on 2/27/22. When asked how long it typically took to get new prescriptions delivered to the facility from pharmacy V25 stated if they get the order by 4:00 PM it will be delivered the next day. V25 stated if they couldn't get them delivered the next day, they would take the medications out of the emergency medication kit (stat safe). When asked if they had [MEDICATION(S)] in the stat safe V25 got the inventory log which documented they had two vials of [MEDICATION(S)] 20 milligrams (mg) per milliliters (ml). On 3/2/22 at 4:13 PM V24 (CNA) stated she provided care to R14 on 2/28/22. When asked if she remembered how R14 was on 2/28/22 V24 stated R14 complained of pain a lot and asked for pain medicine quite often. V24 stated she reported it to the nurse R14 was in pain. V24 stated it was normal for R14 to complain of pain and ask for pain medication. On 3/3/22 at 2:37 PM V22 (Resident Assistant) stated she could not remember what R14's pain was like on 2/28/22 but stated she knew just about every day R14 asked for pain medication. On 3/4/22 at 1:04 PM reviewed with V2 (Director of Nurses/DON) that it took approximately 24 hours for R14's [MEDICATION(S)] to be delivered and that Tylenol was not administered when R14 asked for pain medication until the [MEDICATION(S)] could be obtained. V2 stated he got the [MEDICATION(S)] out of the stat safe for V6 to administer to R14 on 3/1/22. When asked why it wasn't gotten out of the stat safe on 2/28/22 when it was ordered V2 stated, That is a good question. V2 stated it should have been pulled from the stat safe on 2/28/22. On 3/4/22 at 10:52 AM V40 (Pharmacist) stated their pharmacy provides pharmaceutical services to the facility. V40 stated if there is an order that comes in after hours the facility can call the after-hours number and get the medication out of the stat safe. V40 stated if the medication is not in the stat safe the pharmacy can call a local retail pharmacy and have it sent to the facility. This surveyor reviewed with V40 pain medications were charted as not available for 24-48 hours after being ordered and asked if that was an acceptable time frame, V40 stated, No, but they have those meds in the stat safe. V40 reviewed the facility stat safe information and stated they have liquid [MEDICATION(S)] in stock. V40 stated if they didn't have it, they could call the after-hours pharmacy and have it delivered. 2. R2's Resident Face Sheet documents that R2 was admitted to the facility on [DATE] and discharged on [DATE]. The same Face sheet documents R2 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set) dated 2/12/22, section J documents R2 does not have a scheduled pain medication regimen and R2 received as needed pain medications and/or was offered and declined pain medications throughout the five days prior to the assessment. R2's 2/7/22 MDS documents a BIMS (Brief Interview for Mental Status) score of 5, which indicates R2 has a significant cognitive impairment. R2's care plan dated 2/2/22 documents a problem area of Resident admitted to facility for therapy. Family states that they would like for resident to participate in therapy and return to her apartment . R2's care plan also documents a problem area of R2 has chronic bilateral hip pain. Approaches for the problem of pain include Administer pain medication as ordered. Monitor for side effects. Assist resident with non-pharmacological pain relief methods. R2's Medications Administration History dated 2/1/22-2/28/22 note order to assess pain q (every) shift using 0-10 scale or verbal descriptor scale with frequency of bid (twice daily). Special Instruction note to please choose pain level and location in Med Notes. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/8/22 and order for [MEDICATION(S)]-Acetaminophen 5-325mg 1 tab oral every 6 hours (routine) was prescribed. On 2/25/22 at 12:52pm, V13 (family member) said R2 had been in a lot of pain, and nothing was done. V13 also added the facility wanted R2 to ask for pain meds, but R2 had dementia and didn't always know to ask for one. V13 said they were finally able to get the order for pain medicine to be given every couple of hours. On 3/3/22 at 12:30pm, V26 (OT/Occupational Therapist) said he saw R2 for a therapy eval on 2/3/22. V26 said R2 did not want to move a whole lot. V26 said he was only able to get R2 to stand one time and R2 was yelling out in pain. V26 said he told the nurse but cannot remember which nurse he told. R2's Occupational Therapy (OT) Daily Treatment Note dated 2/3/22 by V26 (Occupational Therapist) documents, pt (patient) requesting pain medicine and being in pain in back area. Educated that we were therapy but would notify nursing for pain medication pt (patient) continue to refuse to get out of bed 2/2 (two out of two times) c/o (Complains of) pain in L (Left) hip and back. Repositioned pt in bed c (with) max Ax2 (maximum assistance assist x2 (2 people) for comfort and pt yelling out in pain. Pt repositioned c pillow under buttocks/back and between legs for comfort, nursing notified of pt behavior. On 3/3/22 at 1:00pm, V30 (PTA/Physical Therapy Assistant) said she tried to see R2 on the first day of her therapy (2/3/22). She said she tried to roll her over and R2 yelled out in pain and was in too much pain to do therapy. V30 said she did report it to nursing but doesn't remember the nurses name she reported it to. R2's Physical Therapy (PT) Treatment Note) dated 2/3/22 documents, approached patient for therapy, with pt requesting pain medicine and being in pain in back area. Pt educated that we were here for therapy and could not give any medicine but would go speak with nursing. Pt told this therapist Why are you hurting me?, Therapist went and address pt pain to nursing staff. Nursing reported they would be in contact with DR (Doctor) office pt completed bed mobility rolling with max A x2 person and pt yelled out about her left hip hurting, reported this to nursing as well. R2's medication administration history dated 2/1/22 to 2/28/22 documents pain assessments each shift on 2/3/22 with no pain noted and does not document administration of [MEDICATION(S)] or acetaminophen on 2/3/22. This indicates R2 had pain during the physical and occupational therapy evaluations on 2/3/22 that was not assessed and/or treated by nursing. On 3/3/22 at 2:00pm, V28 (CNA/Certified Nurse Assistant) said on 2/12/2022 her, and another (unknown) CNA put a depend (diaper) and a draw sheet on R2 and R2 kept yelling out in pain. V28 said the nurse (V16) was in the room, so she was aware of R2 having a lot of pain. V28 said that they would let the nurse know about R2's pain each time they went out of the room. On 3/4/22 at 10:54am, V16 (Registered Nurse/RN) said she asked R2 about her pain level on 2/12/22 and R2 was unable to rate her pain and would only say it was burning. V16 stated R2's non-verbal pain indicator was a clenched fist with nothing in it. V16 stated she did not give R2 any pain medication. R2's medication administration history dated 2/1/22 to 2/28/22 documents on 2/12/2022 at 6:00 AM [MEDICATION(S)]-acetaminophen 5 mg (milligrams)-325 mg was held due to drug/item not being available. This same document notes a pain assessment on the 6 AM -6 PM shift with pain assessed as an 8 out of 10. R2's medication administration history does not document [MEDICATION(S)]-acetaminophen or acetaminophen were administered. This indicates R2 had a pain level of 8 out of 10 with no pharmacological interventions administered as ordered by the physician. R2's medication administration history dated 2/1/22 to 2/28/22 also documents on 2/1/22 6 AM- 6 PM, R2's pain was assessed as a 5 out of 10, without any administration of pain medication documented. This same document notes on 2/4/22 and 2/5/22 R2's pain was assessed as 4 out of 10 with no documentation of pain medication being administered. On 3/4/22 at 1:04 PM when asked what his expectations were when a resident was experiencing pain V2 (DON) stated the nurse should assess for pain, document the assessment, treat the pain, and then monitor the treatments effectiveness. On 3/4/22 at 1:23 PM V41 (Physician) stated she would expect facility staff to administer pain medications to control pain. V41 stated residents who are on comfort care measures should have their pain controlled. The facility Pain Management Policy dated 09/10 documents, The Facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy Procedure: 1. Residents will be assessed for pain using the Geriatric Pain Assessment upon admission, quarterly and with any significant change in resident condition. A standardized 0-10 scale of Verbal Descriptor Scale (VDS) will be utilized to determine pain intensity. 2. The physician will then be contacted, if needed, regarding the pain or pain indicators. Licensed staff will document any contact with the physician and the physician's response. 3. An individualized care plan will be developed and implemented. 4. If the resident's pain is not being controlled, a Pain Tracking Log may be implemented to track pain and response to medication and/or treatment. 5. Residents will be monitored until pain is resolved or is under control and periodically thereafter. 6. Licensed staff will document any complaints of pain and the resident's response to the medication/treatment in resident's record. 7. In the event that there are no new medication orders from the physician, licensed staff will continue to monitor the resident's condition, keeping the primary physician informed. 8. The Medical Director will be notified of resident's condition, physician notification and lack of response, should that occur. 9. Alternative methods of pain control will also be attempted .

Based on observation, interview and record review, the facility failed to a) accurately and thoroughly identify pressure ulcers, b) consistently assess and/or document assessments of pressure areas, c) provide dressing changes in accordance with policy and professional standards of practice, d) timely identify and notify physician of worsening pressure ulcers, e) have a system in place to monitor the progression of pressure ulcer(s), and f) follow facility pressure ulcer policy/procedures for 2 (R1, R3) of 3 residents reviewed for pressure ulcers in a sample of 8 residents. These failures resulted in (R3) being hospitalized for an infected stage 3 pressure ulcer and subsequently being put on comfort care after refusing amputation or surgical intervention. Findings include: 1. R3's Face Sheet documents an original admitted [DATE] and latest return on 1/14/2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Hospital History and Physical Exam documented in part, admitted [DATE] and discharge date of [DATE]. Physical Exam: Extremities: [CONDITION(S)] features of both lower legs, redness, swelling, tenderness, Left Heel: Ulcer, unstageable necrotic tissue with purulent drainage. Infectious Disease (ID) Update: Decision has been made to make patient comfort focused treatment only. No surgeries or invasive treatments planned. Those heels will most probably never heal without surgery. Palliative Supportive Care consult documented Plan Do Not Resuscitate (DNR), HPOA (Healthcare Power of Attorney - V14) decided not to proceed with surgical interventions. Transition to comfort focused care and consult hospice. R3's Hospital Discharge Information for Receiving Facility documented a hospital admitted [DATE]. Encounter Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 4, which indicates severe cognitive impairment. This same MDS documents R3 requires extensive assistance for bed mobility, transferring, and toilet use with 2 staff assistance, always incontinent of bowel and bladder, at risk for pressure ulcer/injuries, and no unhealed pressure ulcers or arterial ulcers were present. R3's Admission Braden Assessments nor quarterly Braden Assessments could be found for the dates of 6/16/21 through 1/12/22. R3 was hospitalized from 1/12/2022 to 1/14/2022. R3's Braden assessment dated [DATE] documents a score 12, indicating R3 is at high risk for pressure ulcer development. A Braden Assessment completed on 1/20/2022 documents a score of 15, indicating R3 is at risk for pressure ulcer development. On 2/16/2022 at 2:43 PM, when questioned about R3's Braden Assessments prior to 1/12/22, V1 (Administrator) responded via email she was unable to find (R3)'s Admission and Quarterly Braden Assessments. R3's Care Plan Problem dated 6/17/2021 documented, (R3) is at risk for pressure ulcers related to decreased mobility, generalized muscle weakness following recent illness and hospitalization . The care plan approach, dated 6/30/2021, documented heel protector boots in place at all times, as tolerated. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse areas apply wet to dry with Dakin's. Apply heel protector and wrap with Kerlix [Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Wrap with Kerlix and secure with tape [Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/4/2022 at 3:30 PM, V2 (Director of Nursing/DON) stated (R3) had previous pressure ulcers on admission that healed, and the heel protector boots were in place for prevention since June 2021. On 1/27/2022 at 11:30 AM, V4 (Licensed Practical Nurse/LPN) stated (R3) had pressure areas to her heels which were facility acquired. V4 also stated (R3) had [CONDITION(S)], diabetes, and areas on her heels that were stage IV. V4 said R3 has poor appetites, declining condition, and has been placed on comfort care measures since she returned from the hospital. On 1/27/2022 at 10:00 AM, V3 (Registered Nurse/RN/Treatment Nurse) stated she does all the treatments on the halls. V3 stated R3's Pressure ulcers on her heels were facility acquired. V3 stated she does weekly skin checks and rounds with (V10/Wound Doctor) and documents wounds in the Electronic Health Record (EHR). V3 stated she notifies the Doctor and Family when any new skin areas develop. On 1/27/2022 at 1:20 PM, V3 (RN/Treatment Nurse) brought in the treatment supplies and set them on R3's overbed table without cleaning or placing clean barrier. R3's lunch tray was on this same table. V3 washed hands and donned gloves then removed R3's heel boots, cut off the right foot dressing and revealed the right heel pressure ulcer wound, which appeared approximately a 1/2-dollar size, with a slough in the center, and brownish drainage on the old dressing. V3 forgot tape and left the room. V3 came back to the room and proceeded to cleanse the right heel wound bed with a wet soaked gauze. V3 discarded gauze in the trash, applied the ointment to wound bed, and wrapped the foot with gauze dressing. Without performing hand hygiene, V3 then used the same gloved hands to cut off the left foot dressing, which revealed a larger pressure ulcer covered with black eschar. V3 discarded the old dressings in a trash can by the bed, and with the same gloved hands cleansed the left heel wound, applied a wet soaked gauze dressing, wrapped the left heel with gauze, and applied tape. V3 doffed the gloves in the trash can in the room, then washed her hands in the resident bathroom. On 1/27/22 at 1:30 PM, V3 stated she did not need to perform hand hygiene and put on new gloves between taking off the old dressing and application of the new dressing because the dressing was not a sterile dressing change. On 1/27/2022 at 2:15 PM, V2 (Director of Nursing/DON) stated (V3) was the primary treatment nurse for the facility and he would expect her to wash her hands after she removed an old dressing and before application of a new dressing per the facility policy. R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In November, these are documented as completed every Friday on 11/5/21, 11/12/21, 11/19/21, and 11/26/21. In December, the skin checks are documented as completed on 12/3/21, 12/10/21, 12/17/21, 12/24/21, and 12/31/2021. On the January 2022 MAR, the only documentation noted for R3's skin checks was completed on 1/7/22. There was nothing further entered for skin checks in January, and there is no section to document any description of the skin observations, only that they were completed by the nurse entering their initials on the MAR. This indicates the facility failed to assess and/or document weekly skin assessments on the MAR for the following dates 1/21/22 and 1/28/22. On 2/15/2022 at 2:30 PM, V3 (RN/Treatment Nurse) stated the EHR (Electronic Health Record) alerts her as to who is due for their weekly skin assessments. V3 stated she does a head-to-toe skin assessment and checks the bony prominences and under the skin folds. V3 stated if there were no issues observed she did not document a detailed assessment. V3 stated (R3) had soft/mushy heels prior to the 12/1/2021 pressure ulcer development which was why she had orders for the heel booties and the skin prep to her heels daily. V3 stated during treatments she would sometimes find that (R3) did not have her heel booties on and she would have to go get them from the laundry and re-apply them. V3 stated this happened sometimes and she would reinforce the importance of R3 wearing the heel booties with the CNAs (Certified Nurse Aides). V3 stated it was the Nurses and CNA's responsibility to be sure the heel booties were on, and it wasn't very often that she found (R3) not wearing them. V3 stated (R3) complied with wearing the heel booties and she thought the pressure areas developed due to her overall frail condition. R3's progress notes on 6/17/21 and 9/25/21 document R3's heels were boggy with blanchable redness to bilateral heels. R3's medical record does not document any other thorough assessments of R3's bilateral heels until 12/01/2021. On 2/17/2022 at 12:10 PM, V2 (DON) stated nursing should have been documenting the description of (R3)'s boggy/mushy heels on their weekly skin assessments. On 2/15/2022 at 4:00 PM, V18 (LPN) stated she did (R3)'s skin assessment on 11/12/2021 and both heels' skin was intact but felt soft and mushy. V18 stated she documented the 11/12/21 assessment by signing her initials to R3's MAR, with no description of the areas documented in R3's record. On 2/16/2022 at 7:45 AM, V19 (LPN) stated she did (R3)'s 11/26/2021 skin assessment of both heels and they both had no open areas or heel redness present. V19 stated prior to (R3)'s pressure ulcers developing on the heels she wore the pressure relief booties while she was in bed and slippers when she was up for breakfast or for activities during the day. V19 stated (R3)'s slippers were loose fitting on her feet and did not put pressure on the heels. V19 stated (R3) could kick her heel booties off occasionally and staff would re-apply them. V19 stated the nurses were responsible for application of the heel protectors. V19 stated she documents weekly skin assessments in the EHR progress notes, and if a new pressure area was discovered she would document the wound in an Event note with measurements and description. On 2/15/2022 at 3:30 PM, V17 (CNA) stated she did (R3)'s shower on 11/27/2021 and she did not see any open areas present on (R3)'s heels, and (R3) always wore her heel protectors while she was in her wheelchair and in bed. R3's Progress Notes dated on 12/1/2021 at 8:43 PM documented, this nurse (V18 LPN) observed two pressure ulcers while applying resident's heel boots for bedtime. Pressure ulcer on right heel is measuring 1.5 cm (centimeter) x 2 cm and pressure ulcer on left heel is measuring 2 x 3 cm. Area was cleansed with wound cleanser, calcium alginate and foam dressing applied, along with heel protectors. Resident presents moderate pain to areas. Treatment orders in place and wound management updated for wound doctor to observe and round on resident next time in facility. There was no stage of the pressure ulcers documented at this time. R3's Wound Management Detail Report documents in part, pressure ulcer to left heel (not present on admission or re-entry) identified on 12/01/21 at 8:50 PM that measures 3 cm x 2 cm described as bloody, foul odor, and necrotic type tissue. The Wound Management Detail Report documents pressure ulcer to right heel (not present on admission or re-entry) identified on 12/01/21 at 8:49 PM that measures 2 cm x 1.5 cm described as bloody, foul odor, with necrotic tissue. On 12/10/21, the Observation History section of this report documents No observations have been recorded for this wound for both right and left heels. There are no further entries on this report until 1/21/22 at 9:15 AM (one week after R3 returned from the hospital) when the Observation History section documents, Left Heel length 10.5 cm Width 8 cm. moderate exudates, red to pink watery, slough tissue, Redness/blanchable, wound healing status declining. 1/21/2022 at 9:15 AM Right Heel Length 2.5 cm Width 1 cm light exudate; red to pink, thin and watery, foul wound odor, Slough tissue, edge not attached, [CONDITION(S)], wound healing status declining. On 2/15/2022 at 4:00 PM, V18 (LPN) stated she discovered (R3)'s right and left heel pressure ulcers on 12/1/2021. V18 stated she did the measurements, notified the doctor for a treatment but she did not notify (R3)'s Power of Attorney (POA) because she did not know she was supposed to. V18 stated she documented both heel pressure ulcers description on a Wound Management Detail Report and in the progress notes on 12/1/21. V18 stated she did not put any staging of the wounds because the Treatment Nurse or DON usually does stage (stages the pressure ulcers) and makes the referral to the wound doctor on the next day. V18 stated when she found (R3)'s pressure ulcers on 12/1/2021 to both heels, they were small open areas with a deep red/maroon color to the wound, bloody drainage, with a foul odor, without any black tissue or slough present. V18 stated (R3)'s pressure ulcer on the left heel was worse than the right heel. V18 stated (R3) always had her pressure relief booties on and the nurses made sure they were on every shift. When this surveyor asked V18 what the stage of the pressure ulcers were upon discovery and if the wounds were necrotic tissue as was described on the 12/1/2021 Wound Management Detail Report, V18 stated she was not sure if necrotic tissue was an accurate description because she did not see any black or sloughing tissue on the wound, only the deep red tissue. V18 was unable to confirm what the stage of R3's pressure ulcers were on 12/1/2021. On 2/17/2022 at 8:15 AM, V3 (RN/Treatment Nurse) stated she did treatments to (R3)'s heels on 12/2/2021 and thinks the heels were a stage 2 at the time. V2 stated any nurse can stage a wound and there is a book on the treatment cart that tells the nurses what the wound stages look like. V3 stated she does not keep a wound log. V3 stated the nurses should do weekly measurements and wound descriptions on residents with pressure ulcers. R3's December 2021 Progress Notes dated 12/4/2021 at 6:45 AM, 12/11/2021 at 5:54 AM, 12/25/2021 at 6:23 AM, 1/1/2022 at 2:41 AM, 1/5/2022 at 2:56 PM, 1/6/2022 at 4:31 PM, and 1/11/2022 at 7:06 AM all documented wounds were observed but no wound measurements, staging, or descriptions were included. There is no weekly progress note entered for wound observation on 12/18/21. R3's medical record does not document an assessment including staging of the pressure ulcers on R3's heels from 12/01/21 until 12/10/21 when R3 was evaluated by V10 (Wound Doctor). On 2/15/2022 at 2:30 PM, V3 (RN/Treatment Nurse) stated if there were any new skin issues, or pressure ulcers, she would call the doctor for a treatment order, notify the POA, then chart the measurements and description in the progress notes and on the Event note in the EHR. V3 stated an Event note included the wound location, measurements, drainage, stage and skin color, and she would document weekly descriptions and measurements on a Wound Management Detail Report in the EHR. V3 stated she was not aware she should enter (V10/Wound Doctor)'s measurements into the Wound Management Detail Report and she usually documents (V10)'s measurements in the progress notes. On 2/4/2022 at 3:30 PM, V2 (DON) stated he expected the nurses to document wound measurements on a weekly basis in the Electronic Health Record (EHR) Wound Management Detail Report. V2 stated he expected the nurses to enter (V10/Wound Doctor)'s wound measurements into the EHR Wound Management Detail Report, but the nurses have had issues with this getting done. R3's Progress Notes dated 12/10/2021 at 4:28 PM documented (R3) seen by (V10/Wound Doctor), related bilateral heel ulcers. New orders received. R3's Wound Consultation Progress Note by (V10) dated on 12/10/2021 documented in part, Subjective: Wound Care, Location Left Heel, Right Heel. Severity Moderate, Progression Worsening, Wound Care: Left Heel: Full thickness wound down to subcutaneous tissue, measuring 4.5 cm x 4.0 cm x .2 cm. with no maceration of [CONDITION(S)] noted surrounded wound. Right Heel: Full thickness wound down to subcutaneous tissue, measuring 2.2 cm x 1.5 cm x 0.2 cm with no maceration of [CONDITION(S)] noted surrounded wound. Assessment/Plan Decubitus Ulcer of left heel, Stage 3. Decubitus Ulcer of Right heel, stage 3. R3's medical record does not document a descriptive assessment of the pressure ulcers located on R3's bilateral heels from 12/10/21 until 12/16/21. R3's Progress Notes dated 12/16/2021 at 3:54 PM documented, (V10) in facility rounding on resident at this time. New wound measurements registered are 6.5 cm x 7.5 cm to left heel and 1.5 cm x 1.5 cm to right heel. Continue with current treatment orders. R3's Wound Consultation Progress Note by (V10) dated on 12/16/2021 documented in part, Subjective: Wound Care, Location Left Heel, Right Heel. Severity Moderate, Progression Worsening, Wound Care: Left Heel: Full thickness wound down to subcutaneous tissue, measuring 6.5 cm x 7.5 cm x 0.2 cm with moderate maceration, no [CONDITION(S)] noted surrounded wound. Right Heel: Full thickness wound down to subcutaneous tissue, measuring 1.5 cm x 1.5 x .2 cm with moderate maceration, no [CONDITION(S)] noted surrounded wound. Assessment/Plan Decubitus Ulcer of left heel, Stage 3. Decubitus Ulcer of Right heel, stage 3. R3's medical record does not document an assessment by the facility staff and/or V10 (Wound Doctor) from 12/17/21 until 1/5/22. R3's Progress Notes dated on 1/5/2022 at 2:56 PM document When changing residents bilateral heel dressings, this nurse discovered a foul odor. Standing orders for wound culture processed at this time and obtained. Lab carrier called for pick up. R3's Progress Notes dated on 1/6/2022 at 4:31 PM documented, seen by (V10), verbal order received to X-ray left heel to rule out [CONDITION(S)]. R3's Wound Consultation Progress Note by (V10) dated 1/6/2022 documented in part, wound care left heel: Full thickness wound down to bone, wound measures 7.0 cm x 7.0 cm x 0.1 cm [CONDITION(S)] noted around wound, moderate maceration. No measurements of right heel pressure ulcer. Assessment, Decubitus Ulcer of the Left Heel, stage 4. Patient started on [MEDICATION(S)] for [CONDITION(S)] of the wound. Xray ordered to rule out [CONDITION(S)]. R3's Progress Notes dated on 1/9/2022 at 9:13 AM documented Wound culture results: Moderate Growth of Proteus, Moderate growth Escherichia Coli, Light Growth of Staphylococcus aureus. (MD) orders [MEDICATION(S)] (Antibiotic) twice a day for 7 days. R3's Progress Notes dated 1/12/2022 at 7:04 PM documents, CNA called this nurse into room at this time due to concerns of resident's condition. Resident lethargic and diaphoretic. Vitals as follows: Temp 100.6, Pulse 109, Pulse Oxygen 93%, Respirations 20, Blood Pressure 150/62. This nurse has concerns of possible [CONDITION(S)]. Emergency Medical Services (EMS) to transport to (hospital) for evaluation. Will contact MD (Medical Doctor) and POA. R3's Progress Notes dated on 1/14/2022 at 5:25 AM documented in part, This nurse called (hospital) to get update on resident .(R3)'s current nurse at (hospital) informed this nurse that they have a wound vac on her right foot and are speaking with POA (V14) today, 1/14 regarding a possible amputation of the left foot. R3's Progress notes dated 1/14/2022 at 7:05 PM documented (R3) arrived back to facility at this time via EMS. On comfort care measures. R3's Wound Consult Note by V10 for date of service on 1/20/2022 documented in part, Wound care: Left Heel Full Thickness wound down to bone, copious drainage, wound measures 10.5 cm x 8.0 cm x 1.0 cm. [CONDITION(S)] noted around wound, moderate maceration. Right Heel: Full thickness wound down to subcutaneous tissue, wound measures 2.5 cm x 1.0 cm x 0.2 cm no [CONDITION(S)], minimal maceration noted around wound. Assessment/Plan Decubitus ulcer of left heel, stage 4, Acute [CONDITION(S)] of left foot, Decubitus Ulcer of right heel, stage 3. [CONDITION(S)] of left calcaneus, Continue [MEDICATION(S)] (antibiotic) per Infection Disease, POA decided to keep patient as comfort care with no more surgery. R3's Progress Note dated on 1/21/2022 at 9:98 AM (as late entry) documented as V10 in facility. Wounds to bilateral heels assessed. Wound to left heel is stage 4 measuring 10.5 cm x 8 cm. Verbal orders received to cleanse area, apply wet to dry dressing with Dakin's, apply heel protector and wrap with Kerlix. Right heel is stage 4, measuring 2.5 cm x 1 cm. Cleanse area, apply Santyl, and foam heel protector, wrap with Kerlix. On 2/17/2022 at 9:15 AM, V10 (Wound Doctor) stated when he saw (R3)'s heels for the first time it was on 12/10/2021 and both heels were a stage 3 without sign of infection, and he saw them again on 12/16/2021 and they were a stage 3 without sign of infection. V10 stated he was out of the facility for 3 weeks, and when he came back on 1/6/2022 he saw the left heel had worsened to a stage 4 and was more necrotic to the bone and ordered antibiotics and x-ray. V10 stated (R3) did get hospitalized on [DATE] for the infected pressure ulcers. V10 stated once the necrotic tissue is into the deeper subcutaneous tissue and gets to the bone, surgical interventions like debridement, and antibiotics are usually necessary. V10 stated he was not sure why the pressure ulcer went from the stage 3 to stage 4 in 3 weeks unless she was not always wearing the heel protection, but her stage 3 pressure ulcer with comorbid conditions such as diabetes, malnutrition, and poor circulation would contribute to her risk for infection and poor healing of the wounds. V10 stated he had the hospital records for (R3), and she did not have any wound debridement, or surgery while in the hospital due to the family wishes for comfort care. V10 stated on 1/20/2022 (R3)'s left heel was full of necrotic tissue to the bone and still a stage 4 which contributes to the increased measurements and sizing, and he did not do debridement due to family wishes. V10 stated he did debridement on 2/3/2022 to clean it up more because it was so necrotic. V10 stated if (R3) could take her heel protection off herself she could develop a stage 2 pressure ulcer in a short amount of time and he feels this would have been an unavoidable pressure ulcer development to her heels, because staff could not be with her 24/7. V10 stated while he was not in the facility for 3 weeks, he would have expected the nursing staff to identify any wound regression on staging, or sign of infection, and report these findings to the doctor in his absence. V10 stated he would review pressure ulcer staging with the nursing staff. On 2/17/2022 at 12:10 PM, V2 (DON) stated before this survey all the nurses documented weekly skin assessments by exception and there was no written policy for this. V2 stated when the nurses find a skin issue such as skin tear or bruising, they are expected to document the description and measurements on an Event report and weekly on an Event report thereafter. The Wound Management Detail Report is for pressure ulcer documentation. V2 stated they have identified the issues with wound documentation and are following up with the nursing staff to streamline the process. V2 stated he does not get a written wound report weekly of pressure ulcers and he looks up resident change in condition reports daily, which includes residents with new pressure ulcers. V2 stated they have access to (V10)'s consult reports online. V2 stated (R3) did not have a change in condition prior to the development of pressure ulcers to her heels, and she may have been able to kick off the heel boots at times. V2 stated he did not see her wear shoes, only the heel protection when she was up. V2 stated nursing should have been documenting (R3)'s boggy/mushy heels on the weekly skin assessments. 2. R1's Resident Face Sheet documents an original admitted [DATE], with a last return date of 9/17/2021. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Braden assessment dated , 9/17/2021 documented score of 16.0 which indicates R1 was at risk for pressure ulcer development and on 2/8/2022 documented score of 14 which indicates R1 was at Moderate Risk for pressure ulcer development. R1's Minimum Data Set (MDS) dated [DATE] documents in part, Annual Assessment with a BIMS score of 5, which indicates moderate cognitive impairment. Requires extensive assistance for bed mobility with one person, and extensive assistance for transferring and toilet use with 2 persons. Is occasionally incontinent of bowel and bladder. Resident is at risk of developing pressure ulcer/injuries, and none were present at the time of assessment. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start on 1/4/2022-1/14/2022 [MEDICATION(S)]-pot clavulante tablet; 875-125 mg; amount 1; by mouth twice a day for 10 days and [MEDICATION(S)] capsule; 100mg 1 by mouth for 10 days. [diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start 1/18/22 to End 1/21/2022, Wound cleanser left hip, Calcium (Ca+) Alginate, and secured with foam dressing daily and as needed. Start 1/21/2022 to open ended, Left Hip cleanse with wound cleanser, apply Santyl to sloughy areas, apply [MEDICATION(S)]. Cover with foam dressing once a day. R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .). R1's Event Report entitled, Skin Integrity Events-Skin Tear/Laceration I; Event date of 12/15/2021 09:51 PM, Description: Left Hip: Physical Assessment: Skin Tear, Left Hip 1 cm x 1 cm. Depth shallow, Blood Loss-small amount. Representative Notified: No. Treatments: Cleanse open area to left hip apply foam dressing daily 12/15/2021 to 1/18/2021. And Treatments. Wound Cleanser Left hip, Ca+ Alginate and secure with foam dressing daily and as needed dated 1/18/2022 to 1/21/2022. Evaluation Notes: Change in condition. R1's Progress Notes dated 12/15/2021 at 9:52 PM documented CNA alerted this nurse to new skin area observed while changing resident. Assessment: open area to left hip measuring approximately 1 cm x 1 cm; shallow. Medical Doctor (MD) notified; Treatment cleanse daily and apply foam dressing. Orders processed. R1's Progress Notes dated 12/28/2021 at 4:50 PM documented Resident's left hip wound is red, swollen, hot and foul smelling. Some areas are sloughed, and edges are necrotic in color. Ok to swab for culture per (MD). R1's Progress Notes documented on 1/21/2022 at 7:40 AM, (V10) in facility to see resident, wound to left hip unstageable. Wound debrided, resident tolerated well. Measurements are 3-centimeter x 5.5 cm. Treatment orders to cleanse area, apply Santyl, [MEDICATION(S)] and cover with foam dressing. Low air loss mattress in place at this time. Wedges ordered. Will continue to monitor. R1's wound culture results collected from left hip on 12/28/2021 and verified on 12/31/2021 documented, Heavy Growth of Staphylococcus aureus. The facility was unable to provide reproducible evidence of a Wound Management Detail Report for R1 up to the time of exit on 2/18/2022. On 2/17/2022 at 12:15 PM V2 stated they did not have any further Wound Management Detail Reports on R1 to provide for the survey. V2 stated they have reviewed their wound care policies and documentation expectations with nursing to streamline their wound documentation. On 1/27/2022 at 2:00 PM, V3 (RN/Treatment Nurse) provided wound care to R1's left hip pressure area. The left hip pressure ulcer was unstageable, covered with slough tissue and was approximately 1/2 dollar in size but irregular shape. V3 failed to provide a clean barrier for treatment supplies and failed to perform hand hygiene after removal of the old dressing and before application of the new dressing. V3 stated she did not need to do hand hygiene between removal of the old dressing to application of the new dressing because it was not a sterile dressing change. On 1/27/2022 at 10:00 AM, V3 stated she does all the skin assessments weekly and documents assessments in the Electronic Health Record (EHR) and is expected to notify the doctor and family when new skin issues develop. V3 also stated (R1) had a facility acquired pressure ulcer of her left hip and was currently seeing (V10) the wound doctor weekly. On 1/27/2022 at 2:15 PM, V2 (Director of Nurses/DON) stated that it is expected of nurses as well as facility policy to perform hand hygiene and don gloves before the removal of the old dressing and repeat before application of a new dressing. On 2/4/2022 at 9:22 AM, V10 (Wound Doctor) stated he was off for a few weeks before 12/25/2021 to after 1/1/2022 for the holiday. V10 stated he saw (R1's) left hip when he returned from his few weeks off and the left hip pressure ulcer was unstageable. V10 stated (R1) previously had an area on her right hip they healed out and (R1) apparently favored laying on the left side. V10 stated due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/4/2022 at 3:25 PM, V2 (DON) stated it was facility policy that nursing should notify the doctor and the residents' family when there was a change in resident condition such as a skin tear or pressure ulcers. V2 also stated R1's left hip pressure ulcer started out as a skin tear on 12/15/2021 and developed into an unstageable pressure ulcer on 12/28/2021. V2 stated it was expected of nursing to document wound progress weekly and input wound measurements in the Wound Management Detail Report in the EHR. Facility Pressure Injury Prevention and Treatment Protocol policy, Revised: 07/16, documents in part, Objective and Purpose: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Principles: 1. A skin risk assessment is completed on all residents upon admission and weekly for the first four weeks after admission and quarterly thereafter. H. Weekly individual treatment report will be done and put on clinical chart. Facility Wound Dressing Change (Clean) policy, dated revised on 12/4, documented in part, Objective: 1. To Protect Wound and Promote Healing, 2. To Prevent Irritation, 3. To prevent infection and spread of infection. Procedure: 6. Use towel to establish a clean field. 10. Remove soiled dressing and discard in biohazard bag. Remove gloves, wash hands, and put on new gl

Based on interview and record review the facility failed to administer pain medication according to doctors' orders for one resident (R1) in a total sample of 9 reviewed during a medication review. This failure resulted in R1 having to be hospitalized for [REDACTED]. Findings include: According to R1' s MAR (Medication Administration Record) on 12/25/15 he was to receive [MEDICATION NAME] ([MEDICATION NAME]) 2 mg (milligram) tablets every 6 hours for chronic pain. This was discontinued on 12/29/15. According to the same document the [MEDICATION NAME] 2 mg was changed to every 8 hours for chronic pain on 12/29/15 through the day of discharge to the hospital on [DATE]. Review of R1 ' s chart shows no corresponding documentation with orders received by the doctor to change the medication from every 6 hours to every 8 hours. On 1/15/16 at 10:00 AM According to, E2 DON (Director of Nursing) stated apparently with R1' s [MEDICATION NAME] the nurse did not have the EMAR (electronic medication administration record) in front of her when she transcribed the order and it was inadvertently changed from every 6 hours to every 8 hours and a Medication Error Report had been completed. According to the document titled Medication Error Report for R1 dated 1/15/16 the physician ordered [MEDICATION NAME] 2 mg every six hours and there was a transcription error made According to R1' s nursing note done by E13 LPN(Licensed Practical Nurse) dated 12/24/15 at 3:59 PM, states R1 returned to the facility and is alert and talking to staff. EMT (Emergency Medical Technician) stated that R1 was given [MEDICATION NAME] at hospital for pain relief. According to R1' s Patient Visit Information from the hospital dated 12/24/15 stated R1 was given [MEDICATION NAME] 4 mg by another nursing home facility and then transferred to current facility who transferred to emergency department due to decrease in oxygen saturation and eyes dilated. Discharge orders are to decrease R1 ' s [MEDICATION NAME] to 2 mg by mouth every 6 hours and add [MEDICATION NAME] 5/325 every 4-6 hours for break through pain. There was no documentation in R1 ' s medical record where his primary care physician was aware of visit to the emergency room or change in pain medication. On 1/8/16 at 2:50 PM Z13 (R1 ' s Primary Care Physician) stated he had been taking care of R1 for several years and he had recently been diagnosed with [REDACTED]. Z13 stated he had finally been able to get R1' s pain under control with [MEDICATION NAME] because he had several allergies and they had tried other things such as [MEDICATION NAME] that had not been effective and that' s why he had put R1 on the [MEDICATION NAME] was because it was able to control his pain the best. Z13 stated R1 was on his way to his first palliative [MEDICAL CONDITION] treatment at [MEDICAL CONDITION] center when he was experiencing so much pain; he apparently almost passed out so the transport van brought him to the emergency room because they were so concerned. Z13 stated the report he received from the attending at the emergency room was that his urine drug screen was negative for any opioids and there was no way that test should be negative if R1 was getting his [MEDICATION NAME] at the facility. Z13 stated he had concerns about his patients care at the facility prior to this as well. Z13 stated as a result of the facility not taking care of R1' s pain and giving him his pain medication that R1' s [MEDICAL CONDITION] treatment was delayed, R1 spent multiple days in the hospital that was not necessary and R1' s pain and pain medication had to be re-addressed and fixed. Z13 stated he is not aware of any orders he or anyone had given to change any of R1' s pain medications since his admission. Z13 stated he told the emergency room doctor to admit R1 because he did not think the nursing home had been managing his pain or taking care of him. According to R1' s MAR for January 2016, R1 was to receive [MEDICATION NAME] 2 mg tablets every 8 hours by mouth at 12:00 AM, 8:00 AM & 4 PM. On 1/5/16 R1 received [MEDICATION NAME] 2 mg at 12:00 AM and did not receive his next dose until 10:50 AM even though it was due to be given at 8:00 AM. R1' s [MEDICATION NAME] was given over an hour and half late on the day he was admitted to the hospital for pain management. On 1/5/16 at 4:35 PM, Z17 (RN-Registered Nurse at the Emergency Department) stated R1 had come into the Emergency Department where he was working and helped take care of R1 while he was there. Z17 stated that according to R1' s record he was to be getting [MEDICATION NAME] on a regular basis and had [MEDICATION NAME] for breakthrough pain. Z17 stated he had called the facility and he had spoken with a nurse and she had told him that R1 had received his last [MEDICATION NAME] at 11:00 AM. Z17 stated the attending had ordered a urine drug screen and it had been negative for opioids. Z17 stated R1 was admitted to the hospital after the PA spoke to the primary care physician for back pain and observation. According to the facility policy titled Medication Administration with revision date 02/04 the objective is to provide the resident with those medications deemed necessary by the physician to improve and/or stabilized specified [DIAGNOSES REDACTED]. All medications must be administered to the resident in the manner and method prescribed by the physician.

Based on interview, observation and record review the facility failed to provide voiced controlled pain management and pain medication and evidence of opiods use for pain for two residents (R1, R3) in the sample of 6 reviewed for pain. This failure resulted in R1' s palliative pain [MEDICAL CONDITION] treatments being delayed, multiple days in the hospital for pain management, comfort and pain medication adjustment. Findings include: 1.) On 1/5/16 at 4:45 PM, Z16 PA (Physician Assistant) stated he had just taken care of R1 in the Emergency Department at the hospital. Z13 stated the information he received was R1 was on the way to his first [MEDICAL CONDITION] treatment for [REDACTED]. Z13 stated he always runs urine drug screens when anyone comes through the Emergency Department. Z13 stated R1' s was negative for Opiates. Z13 stated according to R1' s records he was to be receiving [MEDICATION NAME] on a regular scheduled basis and [MEDICATION NAME] for breakthrough pain as needed. Z16 stated if R1 was receiving his [MEDICATION NAME] and [MEDICATION NAME] according to the Physician orders [REDACTED]. Z13 stated he was even more concerned when he had the nurse administer [MEDICATION NAME] IV (intravenous) at a fourth of a dose that R1 normally received orally and R1 had instant relief. Z13 stated if R1 had been getting his pain medications according to the orders for the past three weeks that type of response was questionable and R1 should have somewhat of a tolerance to the [MEDICATION NAME] at this point. Z13 stated R1 described his pain as being excruciating and voiced it as 10 out of 10 on a 1-10 pain scale. Z13 stated he had called R1's primary care physician and was told to admit him to the hospital for observation and pain management because it was obvious the nursing home could not or was not doing this or taking care of R1 correctly. On 1/5/16 at 4:35 PM, Z17 (RN-Registered Nurse at the Emergency Department) stated R1 had come into the Emergency Department where he was working and helped take care of R1 while he was there. Z17 stated he had called the facility and he had spoken with a nurse and she had told him that R1 had received his last [MEDICATION NAME] at 11:00 AM. Z17 stated this was not the first time R1 has come from the facility when he had been working in the emergency department and had to take care of R1 due to pain issue and he was transferred from the facility for this then also. Z17 stated R1 had been in the Emergency Department around Christmas time and R1 had to be treated for [REDACTED]. Z17 stated the Z16 ordered a urine drug screen and it was negative for opiates. Z17 stated when he had given R1 a fourth of the dose he would receive for [MEDICATION NAME], which the Emergency Department attending ordered, R1 had instant relief. Z17 stated R1 was admitted to the hospital after the PA spoke to the primary care physician for back pain and observation. On 1/8/16 at 2:50 PM Z13 (R1' s Primary Care Physician) stated he had been taking care of R1 for several years and he had recently been diagnosed with [REDACTED]. Z13 stated he had finally been able to get R1's pain under control with [MEDICATION NAME] because he had several allergies and they had tried other things such as [MEDICATION NAME] that had not been effective. Z13 stated he had put R1 on the [MEDICATION NAME] because it was able to control his pain the best. Z13 stated R1 was on his way to his first palliative [MEDICAL CONDITION] treatment at [MEDICAL CONDITION] center when he was experiencing so much pain; he apparently almost passed out so the transport van brought him to the emergency room . Z13 stated the report he received from the attending at the emergency room was that his urine drug screen was negative for any opioids and there was no way that test should be negative if R1 was getting his [MEDICATION NAME] at the facility. Z13 stated he had concerns about his patients care at the facility prior to this as well. Z13 stated as a result of the facility not taking care of R1' s pain and giving him his pain medication that R1' s [MEDICAL CONDITION] treatment was delayed, R1 spent multiple days in the hospital that was not necessary and R1' s pain and pain medication had to be re-addressed and fixed. Z13 stated he is not aware of any orders he or anyone had given to change any of R1' s pain medications since his admission. Z13 stated he told the emergency room doctor to admit R1 because he did not think the nursing home had been managing his pain or taking care of him. According to R1' s Patient Care Summary from the hospital in the Emergency Department dated 1/5/16 at 12:35 R1 has a tumor on his rectum and needs something for pain. R1 is reluctant to answer questions and is refusing to sit appropriately in wheelchair. R1 has a history of [MEDICAL CONDITION] with metastasis to the bone and take [MEDICATION NAME] and [MEDICATION NAME] Routinely. Pain is rated at a 9 on a 1-10 scale in intensity and location is rectum. According to R1' s drug screen from the hospital dated 1/5/16 at 1:28 PM, he is negative for Opiates. According to the facility nursing noted done by E5 LPN on 1/7/16 at 8:20 AM R1 was admitted to the hospital with [REDACTED]. According to R1' s nursing note done by E13 LPN(Licensed Practical Nurse) dated 12/24/15 at 3:59 PM, states R1 returned to the facility and is alert and talking to staff. EMT (Emergency Medical Technician) stated that R1 was given [MEDICATION NAME] at hospital for pain relief. According to R1' s Patient Visit Information from the hospital dated 12/24/15 stated to decrease R1' s [MEDICATION NAME] to 2 mg by mouth every 6 hours and add [MEDICATION NAME] 5/325 every 4-6 hours for break through pain. There was no documentation in R1' s medical record where his primary care physician was aware of visit to the emergency room or change in pain medication. According to R1' s MAR (Medication Administration Record) on 12/25/15 he was to receive [MEDICATION NAME] ([MEDICATION NAME]) 2 mg (milligram) tablets every 6 hours for chronic pain. This was discontinued on 12/29/15. According to the same document the [MEDICATION NAME] 2 mg was changed to every 8 hours for chronic pain on 12/29/15 through the day of admission to the hospital on [DATE]. Review of R1' s chart shows no corresponding documentation with orders received by the doctor to change the medication from every 6 hours to every 8 hours. On 1/15/16 at 10:00 AM According, E2 DON (Director of Nursing) stated apparently with R1' s [MEDICATION NAME] the nurse did not have the EMAR (electronic medication administration record) in front of her when she transcribed the order and it was inadvertently changed from every 6 hours to every 8 hours and a Medication Error Report had been completed According to R1' s MAR for January 2016, R1 was to receive [MEDICATION NAME] 2 mg tablets every 8 hours by mouth at 12:00 AM, 8:00 AM & 4 PM. On 1/5/16 R1 received [MEDICATION NAME] 2 mg at 12:00 AM and did not receive his next dose until 10:50 AM even though it was due to be given at 8:00 AM. R1' s [MEDICATION NAME] was given over an hour and a half late on the day he was admitted to the hospital for pain management. On 1/6/16 at 1:30 PM, R1 stated he was admitted to the hospital yesterday because he was hurting so bad and the pain was just excruciating. R1 stated he knew he was supposed to have [MEDICATION NAME] every six hours at the nursing home and could also get the [MEDICATION NAME] if he needed it. R1 stated he did not know what medications he was getting or not because when the nurses gave him medicine they never told him what it was for. R1 stated he was hurting all the time and was usually an 8 or above. R1 stated there were times he had requested pain medications and no one would answer his call light for over an hour so he didn' t know when or if he could get something for pain or not. R1 stated that once he had gotten to the emergency room yesterday and they gave him the medicine through the IV he had immediate relief and could move without hurting. R1 stated part of the problem was he had a tumor on his rectum and they wanted him to get up in a wheelchair and no one seem to want to listen when he would try to explain why it was more comfortable for him to be in a more laying position rather than sitting up. R1 stated no one seems to understand why he did not want to get up in the wheelchair and that it was very uncomfortable when he did this and then he couldn' t get medicine for the pain. R1 stated the jostling with the transfers also caused him to be very uncomfortable and hurt too and the staff were always in a hurry and never took enough time and needed to be slower and may not have been as painful. According to R1's nursing note on 12/26 /15 at 6:27 PM Resident ate very little, states his right hip hurts but pain is chronic and medication does not really help. No documentation doctor or POA aware of pain and poor appetite. According to R1's nursing note done by E5 LPN(Licensed Practical Nurse) on 12/29/15 at 10:25 AM noted faxed to primary care physician's office regarding resident for indwelling catheter due to pain when straight catheterization done and resident and urine output not being consistent awaiting return message. No documentation noted where nursing attempted to call and speak with primary care physician or notify POA. On 1/14/16 at 1:00 PM E5 stated she could not remember why she did not call R1's doctor on 12/29/15 regarding his pain or issues with his catheter or why she did not call the POA. E5 stated that sometimes it gets really busy and they don't get time to do everything. E5 stated R1 would complain of pain with the straight catherization and have facial indicators of pain such as facial grimacing and yell out Oh Oh, that doesn't feel right. E5 stated R1's order was to straight catheterize two to three times a day. According to R1' s Brief Mental assessment dated [DATE] he scores is 15 out of 15 and able to answer questions appropriately. On 1/12/16 at 9:00 AM, E2 DON(Director of Nursing) stated R1 was still in the hospital receiving treatment. 2.) On 1/7/16 at 12:05 PM, E10 CNA (Certified Nursing Assistant) and E20 COTA (Certified Occupational Therapy Assistant) went to get R3 up out of bed for lunch. During assist with the transfer from the bed to the wheelchair R3 stated It hurts, it stings, oh, oh, stings terrible, it' s so sensitive, the pain is terrible R3 stated these multiple times and she was visibly shaking in her legs and hands and head. R3 also stated can you please stop and I don' t want to go to the dining room to eat lunch, I can 't stand this . R3 stated I don' t know why you can' t wait they haven' t even given me my pain medication and I don' t know why Why can' t I get my [MEDICATION NAME] and [MEDICATION NAME] and wait for it to start working first, then maybe we can try E10 and E20 proceeded to get R3 up even though she continued to complain of pain and had facial grimacing and voiced concerns about not receiving medication and then took her to the dining room. E20 stated they had been working with R3 and she was [MEDICAL CONDITION] and this seemed to be more of a behavior even though in the last week she seems to be having an increase in her pain level. According to R3' s MAR for January 2016, she is to receive [MEDICATION NAME] 10 mg every 6 hours for pain in left hip. On 1/7/16 she was to receive it at 11:00 AM and she did not get it until 12:22 PM. R1 was also to receive [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 2 tablets every six hours for pain and on 1/7/16 R1 was to receive this at 11:00 AM and did not get until 12:22 PM, both of these were over an hour past time for them to be administered. According to R3' s Brief Mental Assessment done 12/25/15 she is able to make needs known and makes appropriate decisions for herself. According to the facility policy titled Pain Management with last revision date of 09/10 the facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy and the purpose is to identify residents experiencing pain to establish control of pain to the resident' s satisfaction and to relieve related symptoms and this is the responsibility of all staff. Under Procedure: -Residents will be assessed for pain using the Geriatric Pain Assessment upon admission, quarterly and with any significant change in resident ' s condition. A standardized 1-10 scale or Verbal Descriptor Scale (VDS) will be utilized to determine pain intensity. -The physician will then be contacted, if needed, regarding the pain or pain indicators. Licensed staff will document any contact with the physician and the physicians' response. -An individualized care plan will be developed and implemented -Residents will be monitored until pain is resolved or is under control and periodically thereafter -Licensed staff will document any complaints of pain and the resident' s response to the medication/treatment in resident' s record. -In the event that there are no new medications ordered from the physician, licensed staff will continued to monitor the residents condition, keeping the primary physician informed. According to the facility policy titled Medication Administration with revision date 02/04 the objective is to provide the resident with those medications deemed necessary by the physician to improve and/or stabilized specified [DIAGNOSES REDACTED]. All medications must be administered to the resident in the manner and method prescribed by the physician.

Based on observation, interview, and record review, the facility failed to administer Schedule II pain medication routinely as ordered and failed to administer an antibiotic for 7 days after the initial order for 2 of 4 residents reviewed for medication in the sample of 7. This failure resulted in R3 enduring pain of at least a pain level of 8 on a 1-10 scale for 3 days,and being unable to maintain normal routine of being up in wheelchair during the day and taking meals in dining room, due to increased levels of pain. Findings include: 1. According to R3's Profile Sheet, R3 was admitted to the facility on [DATE]. A list of R3's [DIAGNOSES REDACTED]. R3's Care Plan initiated on 10/08/2014, identifies pain as a problem for R3 due to [DIAGNOSES REDACTED]. The Goal for this Problem Area listed as : Will have decreased Risk of unmanaged pain through next review Approaches for pain management start date of 10/10/2014 include: Administer prescription as ordered, 'Monitor for breakthrough pain and address promptly, R3 prefers to be awakened during the night for pain medication. R3' physician's orders [REDACTED]. On 9/15/2015 at 11: 36 R3 was sitting in her room in wheelchair. On this same day R3 was observed in the dining room in wheelchair for the midday meal. R3 was observed on 9/16/2015 at 7:35 a.m. in the dining room for breakfast. On 9/17/2015 R3 sitting in wheelchair and engaged in conversation with surveyor. On 9/15/2015 at 12:34 p.m., E3, Assistant Director of Nursing, confirmed that R3's [MEDICATION NAME] was not ordered in a timely manner, resulting in R3 missing 6 doses of [MEDICATION NAME]. R3's MAR for 9/2015 indicates that R3 did not receive the medication from 9/7/2015 at 6:00 a.m. through 9/8/2015 at 4:16 p.m. The reasons documented on the MAR for the doses not being given are, Not Administered: Drug Unavailable, and Not Administered: new script needed. On 9/16/2015 at 11:30 a.m., E6, Registered Nurse, that she gave R3 Tylenol on 9/7/2015 and R3's pain was mild at that time. E6 stated E6 did not work on 9/8/2015 but returned on 9/9/2015 and noted that stayed in bed due to discomfort. On 9/17/2015 at 11:10 p.m., R3 stated during the time when the [MEDICATION NAME] was not available that she asked to stay in bed due to increased pain in her back. R3 stated that she prefers to be up in the wheelchair during the day. A Progress Note for R3 dated 9/8/ at 3:14 p.m. states Resident was in tears this a.m. stating her back hurt so bad. Resident screamed to put her back to bed. Resident did not eat breakfast and refused to get up for lunch. Lunch was fed to her by CNA (Certified Nurses Aid) Multiple phone calls made to and faxes made to Z5's (R3' physician ) office A Progress Note dated 9/9/2015 for R3 at 2:26 p.m. that R3 stayed in bed related to pain. A Progress Note dated 12:21 p.m. states Writer called Z5's office and spoke with nurse. Writer stated resident (R3) had missed 6 doses [MEDICATION NAME] related to no current script on file at pharmacy ( 9/7/2015 9/8/2015). Received a dose on 9/8/2015 at 1615 (4:15 p.m.) per progress note with routine schedule resuming. Resident ( R3) has received 6 doses of prn ( as needed) Tylenol and utilizing hot packs since 9/7/2015 as of note. resident given routine [MEDICATION NAME] at 11:23 and rated pain at 10/10 with hot applied. Per Z5's nurse report, Z5 stated to continue as needed Tylenol and hot packs as previously done. It will take a few days for pain to subside and return to her normal. No new orders at this time. Writer then called back to inquire on parameters for hot packs, waiting on call back. Will continue to monitor. Pain assessments on 1-10 scale for R3 for were recorded R3's MAR for each shift beginning with day shift as follows : (9/7/2015- 0 8,0) ( 9/8/2015-9,9,8) (9/9/2015-5,7,8,) (9/10/2015-10,6,8). 2. R2 s MDS (Minimum Data Set) of 8/6/2016 list of [DIAGNOSES REDACTED]. Documentation on R2's physician's orders [REDACTED]. A Progress Note for R2 dated 9/01/2015 at 6:33 a.m. documents that R2 fell in his room and sustained a laceration to the right ring finger and call placed to Z4, (R2 ' s physician). A Progress Note for R3 dated 9/03/2015 at 2:31 p.m., and written by Z3 (Hospice Nurse) states right ring finger and hand are swollen and red, contacted Z4 and received new order for Bactrim DS 1 tablet twice daily for 7 days. R2 ' s Medication Administration Record for 9/2015 indicates that R2 did not start receiving Bactrim DS until 9/10/2015. On 9/16/2015 at 9:17 a.m., E3, Assistant Director of Nursing, verified that an order had been received for the Bactrim DS for R2 on 9/3/2015., that the order did not get transcribed and was not started until 7 days later on 9/10/2015. On 9/17/2015 at 12:01 p.m., when asked about the appearance of R2s right ring finger between 9/7/2015 and 9/10/2015, E8, LPN ( Licensed Practical Nurse) stated that initially R2 ' s finger looked a little discolored and with a little [MEDICAL CONDITION] but did not not seem unusually warm and that the appearance did not seem to change much during that time, it didn't get better and it didn't get worse. E8 further stated that now it seems to be improving, but slowly. On 9/17/2015 at 2:07 p.m., E11, Registered Nurse, stated that between 9/3/2015 and 9/10/2015 R2's right ring finger appeared red, a little inflamed, it didn't get any worse, but now it is improving E11 further stated that he checked R2 multiple times for pain and R2 never complained of pain. A Physician-Monthly Visit for R2 dated 9/11/2015 at 9:31 a.m., states, [DIAGNOSES REDACTED], warmth, and [MEDICAL CONDITION] to right index finger consistent with [MEDICAL CONDITION]. On 9/15/2015 at 9:10 a.m., R2 's finger appeared reddened, slightly swollen, and the position appeared natural.

Based on observation, interview, and record review, the facility failed to administer routine pain medication for one of four residents (R3) reviewed for pain medication in the sample of 7. This failure resulted in R3 enduring pain of at least a pain level of 8 on a 1-10 scale for 3 days,and being unable to maintain normal routine of being up in wheelchair during the day and taking meals in dining room, due to increased levels of pain. Findings include: According to R3's Profile Sheet, R3 was admitted to the facility on [DATE]. A list of R3's [DIAGNOSES REDACTED]. R3's Care Plan initiated on 10/08/2014, identifies pain as a problem for R3 due to [DIAGNOSES REDACTED]. The Goal for this Problem Area listed as ; Will have decreased Risk of unmanaged pain through next review Approaches for pain management start date of 10/10/2014 include: Administer prescription as ordered, 'Monitor for breakthrough pain and address promptly, R3 prefers to be awakened during the night for pain medication. R3' physician's orders [REDACTED]. On 9/15/2015 at 11:36 R3 was sitting in her room in R3's wheelchair. On this same day R3 was observed in the dining room in wheelchair for the midday meal. R3 was observed on 9/16/2015 at 7:35 a.m. in the dining room for breakfast. On 9/17/2015 R3 was sitting in wheelchair and engaged in conversation with surveyor. On 9/15/2015 at 12:34 p.m., E3, Assistant Director of Nursing, confirmed that R3's [MEDICATION NAME] was not ordered in a timely manner, resulting in R3 missing 6 doses of [MEDICATION NAME]. R3's MAR for 9/2015 indicates that R3 did not receive the medication from 9/7/2015 at 6:00 a.m. through 9/8/2015 at 4:16 p.m. The reasons documented on the MAR for the doses not being given are, Not Administered: Drug Unavailable, and Not Administered: new script needed. On 9/16/2015 at 11:30 a.m., E6, Registered Nurse, that E6 gave R3 Tylenol on 9/7/2015 and R3's pain was mild at that time. E6 stated she did not work on 9/8/2015 but returned on 9/9/2015 and noted that R3 stayed in bed due to discomfort. On 9/17/2015 at 11:10 p.m., R3 stated during the time when the [MEDICATION NAME] was not available that she asked to stay in bed due to increased pain in her back. R3 stated that she prefers to be up in the wheelchair during the day. A Progress Note for R3 dated 9/8/ at 3:14 p.m. states Resident was in tears this a.m. stating her back hurt so bad. Resident screamed to put her back to bed. Resident did not eat breakfast and refused to get up for lunch. Lunch was fed to her by CNA .(Certified Nurses Aid) Multiple phone calls made to and faxes made to Z5's (R3' physician ) office A Progress Note dated 9/9/2015 for R3 at 2:26 p.m. that R3 stayed in bed related to pain. A Progress Note dated 12:21 p.m. states Writer called Z5's office and spoke with nurse. Writer sated resident (R3) had missed 6 doses [MEDICATION NAME] related to no current script on file at pharmacy (9/7/2015 9/8/2015). Received a dose on 9/8/2015 at 1615 (4:15 p.m.) per progress note with routine schedule resuming. Resident (R3) has received 6 doses of prn (as needed) Tylenol and utilizing hot packs since 9/7/2015 as of note. resident given routine [MEDICATION NAME] at 11:23 and rated pain at 10/10 with hot applied. Per Z5's nurse report, Z5 stated to continue as needed Tylenol and hot packs as previously done. It will take a few days for pain to subside and return to her normal. No new orders at this time. Writer then called back to inquire on parameters for hot packs, waiting on call back. Will continue to monitor. Pain assessments on 1-10 scale for R3 for were recorded R3's MAR for each shift beginning with day shift as follows : (9/7/2015- 0 8,0) ( 9/8/2015-9,9,8) (9/9/2015-5,7,8,) (9/10/2015-10,6,8).